Cauda Equina Syndrome Associated with Dural Ectasia in Chronic Anlylosing Spondylitis

Cauda equina syndrome (CES) associated with dural ectasia is a rare neurologic complication in patients with longstanding ankylosing spondylitis (AS). We report a 68-year-old male with a 30-year history of AS who presented a typical symptom and signs of progressive CES, urinary incontinence and neuropathic pain of the lumbosacral radiculopathy. Computed tomography (CT) and magnetic resonance imaging (MRI) findings showed the unique appearances of dural ectasia, multiple dural diverticula, erosion of posterior element of the lumbar spine, tethering of the conus medullaris and adhesion of the lumbosacral nerve roots to the posterior aspect of the dural ectasia. Considering the progressive worsening of the clinical signs, detethering of the conus medullaris through resection of the filum terminale was performed through a limited laminectomy. However, the urinary incontinence did not improve and there was a partial relief of the neuropathic leg pain only. The possible pathogenetic mechanism of CES-AS and the dural ectasia in this patient with longstanding AS are discussed with a literature review.     

Lumbar radiculopathy in ankylosing spondylitis with dural ectasia.

We present a 57-year-old man with ankylosing spondylitis (AS) and significant dorsal lumbar dural ectasia (diverticulum). An L5 nerve root monoradiculopathy associated with AS has not been previously reported. The quantity and extent of such ectasia is variable but may be related to cauda equina syndrome. Long-term follow-up of these cases may reveal whether or not solitary nerve lesions gradually lead to cauda equina syndrome. We recommend that asymptomatic or symptomatic patients with dural ectasia should be closely observed without need for immediate surgical intervention.     

Cauda equina syndrome caused by a migrated bullet in dural sac

Cauda equina syndrome (CES) is a serious neurological condition and the most common cause is a central disc herniation. Migration of a bullet down the spinal canal is uncommon. In this report, the authors present an unusual case of cauda equina syndrome caused by a migrated bullet in dural sac. The patient's cauda equina syndrome was related to possible compression of cauda equina resulting from both bone fragments in L1 level and bullet itself in S2 level. The patient's symptoms and neurological deficits resolved considerably after surgery. In our opinion, it is important to pay attention to diversity of injury when confronted with a gunshot wound. It is essential to perform early and sufficient surgical decompression of the cauda equina to provide a better postoperative neurological recovery.     

Cauda equina syndrome associated with multiple lumbar arachnoid cysts in ankylosing spondylitis: improvement following surgical therapy.

A case of cauda equina syndrome with multiple lumbar arachnoid cysts complicating ankylosing spondylitis (AS) is described. The value of computerised tomography (CT) and magnetic resonance imaging (MRI) as a non-invasive means of establishing the diagnosis is emphasised. In contrast to previously reported cases the patient showed neurological improvement following surgical therapy. Surgery may be indicated in some patients, particularly when there is nerve root compression by the arachnoid cysts and when the patient is seen early before irreversible damage to the cauda equina has occurred.     

Cauda equina syndrome in ankylosing spondylitis: a report of six cases.

Six patients with ankylosing spondylitis and features of a cauda equina syndrome are described. The myelographic findings are discussed in relation to the pathogenesis of the disorder and its natural history. Present experience suggests that the cauda equina syndrome is a more common complication of ankylosing spondylitis than is usually thought.     

Radiculopathy as a complication of ankylosing spondylitis.

A cauda equina syndrome in association with ankylosing spondylitis is well recorded. We report the occurrence of an upper limb radiculopathy which progressed to a cauda equina syndrome in association with ankylosing spondylitis.     

Cerebrospinal fluid dynamics in the tardive cauda equina syndrome of ankylosing spondylitis

Typical cauda equina syndrome secondary to long-standing ankylosing spondylitis is reported in a 63-year-old man. Radionuclide cisternography demonstrated a resorption defect of cerebrospinal fluid in the enlarged lumbosacral dural sac. After transient symptomatic improvement with acetazolamide, a lumboperitoneal shunt was placed. The rate of cerebrospinal fluid, isotope resorption became normal. In the 5 years of follow-up, partial remission has been observed.     

Minimally invasive discectomy for the treatment of disc herniation causing cauda equina syndrome

Cauda equina syndrome (CES) is a condition associated with significant morbidity that requires definitive surgical decompression of the nerve roots to prevent permanent disability. Traditionally, wide open decompression has been advocated to obtain optimal decompression with minimal complications. Some have been reluctant to employ minimally invasive strategies to treat urgent conditions. The authors present a small series of four patients who presented with CES and were treated with minimally invasive discectomy (MID). Operative length times (mean ± standard deviation, 102.8 ± 30.9 minutes) were comparable to reported operative length for open laminectomies. All patients had either stabilization or resolution of symptoms at the 6-week follow-up examination. No patients suffered a cerebrospinal fluid (CSF) leak post-operatively. This series of patients presenting with CED at a single institution treated with MID demonstrates that MID can be used to successfully treat CES. Even large fragments can be safely removed without increased risk of a CSF leak.     

Lumbosacral epidural lipomatosis causing rapid onset cauda equina syndrome

Spinal epidural lipomatosis (SEL) is a rare cause of cauda equina syndrome (CES), which must be diagnosed with MRI in conjunction with a high level of clinical suspicion. Most reported cases are associated with obesity, steroid use or are secondary to endocrinopathies, frequently present subacutely or chronically, and have been managed with both surgical decompression and non-operative measures. We describe an obese 55-year-old man with rapid onset CES secondary to idiopathic lumbosacral SEL which was managed successfully with surgical decompression. Although often thought to be a trivial radiological finding, it is important not to be dismissive of patients presenting with compressive neuropathy and MRI evidence of space-occupying SEL.     

The Incidence and Management of Dural Tears and Cerebrospinal Fluid Leakage during Corrective Osteotomy for Ankylosing Spondylitis with Kyphotic Deformity

ObjectiveTo present the incidence and management of dural tears and cerebrospinal fluid leakage during corrective osteotomy [Pedicle Subtraction Osteotomy (PSO) or Smith-Petersen Osteotomy (SPO)] for ankylosing spondylitis with kyphotic deformity.MethodsA retrospective study was performed for ankylosing spondylitis patients with fixed sagittal imbalance, who had undergone corrective osteotomy (PSO or SPO) at lumbar level. 87 patients were included in this study. 55 patients underwent PSO, 32 patients underwent SPO. The mean age of the patients at the time of surgery was 41.7 years (21-70 years). Of the 87 patients, 15 patients had intraoperative dural tears.ResultsThe overall incidence of dural tears was 17.2%. The incidence of dural tears during PSO was 20.0%, SPO was 12.5%. There was significant difference in the incidence of dural tears based on surgical procedures (PSO vs. SPO) (p<0.05). The dural tears ranged in size from 12 to 221 mm². A nine of 15 patients had the relatively small dural tears, underwent direct repair via watertight closure. The remaining 6 patients had the large dural tears, consequently direct repair was impossible. The large dural tears were repaired with an on-lay graft of muscle, fascia or fat harvested from the adjacent operation site. All patients had a successful repair with no patient requiring reoperation for the cerebrospinal fluid leak.ConclusionThe overall incidence of dural tears during PSO or SPO for ankylosing spondylitis with kyphotic deformity was 17.2%. The risk factor of dural tears was complexity of surgery. All dural tears were repaired primarily using direct suture, muscle, fascia or fat graft.     

Computerized tomography. An adjunct to early diagnosis in the cauda equina syndrome of ankylosing spondylitis

This article describes a case of the cauda equina syndrome associated with ankylosing spondylitis. The typical myelographic features and the computerized tomography (CT) scan of the lumbar spine are included. The CT scan may aid in elucidating the pathogenesis of the disorder.     

Cauda equina syndrome revealing neuroblastoma

IntroductionNeuroblastoma is the most common solid tumor of childhood. Neurological involvement is rare resulting from cord or nerve compression.Case reportA 7-year-old child was hospitalized for cauda equina syndrome. MRI showed retroperitoneal lesion with dumbbell intradural spreading. Blood and urinary catecholamine level were elevated confirming the diagnosis of neuroblastoma. She was treated with chemotherapy alone with partial neurological recovery.Discussion and conclusionCauda equina compression revealing neuroblastoma is exceptional especially at an early phase in the youngest patients. Treatment is based on surgical resection and/or chemotherapy and/or radiation therapy. Long-term prognosis is sometimes poor with neurological sequels.     

Spinal metastasis of occult lung carcinoma causing cauda equina syndrome.

Cauda equina syndrome (CES) may be caused by tumor, herniated disc, trauma and spinal infections. However, CES due to occult lung cancer has not been reported in the literature. A 50-year-old man presented with a subacute CES caused by an intradural metastasis of an adenocarcinoma of the lung to the lumbosacral cauda fibers. His lumbosacral magnetic resonance imaging (MRI), showed a well-demarcated, intradural extramedullary mass lesion resembling a neurinoma at the L4/5 level. The patient underwent an L4-L5 laminectomy. The operative findings were also suggestive of neurinoma with involvement of three nerve roots, and a well-demarcated tumor without infiltration into the subarachnoid space. Although the findings of the operation were suggestive of neurinoma, final pathological diagnosis revealed metastatic carcinoma. Immunohistochemistry revealed clear cell adenocarcinoma metastasis. Chest X-ray and high resolution contrasted pulmonary computed tomography were normal. Positron emission tomography (PET) showed a lung mass, at the left apex. The patient was treated with chemotherapy and post-operative spinal radiotherapy was also performed. The CES resolved after the operation and the patient was followed up for 2 years with no recurrence. MRI of intradural cauda equina metastasis may be similar to that of intradural nerve sheath tumor. Surgery and postoperative radiotherapy may be effective for the treatment of CES due to lung carcinoma. Definitive diagnosis is by histopathological examination with immunohistochemistry. If the primary cancer cannot be detected by conventional radiological techniques, PET may be helpful.     

Surgical Experience of Neglected Lower Cervical Spine Fracture in Patient with Ankylosing Spondylitis

The management of lower cervical fractures in patients with ankylosing spondylitis (AS) differs from normal cervical fractures. Patients with AS are highly susceptible to extensive neurologic injuries and spinal deformities after cervical fractures from even minor traumatic forces. These injuries are uniquely complex, require careful imaging assessment, and aggressive surgical management to optimize spinal stability and functional outcomes.     

Cauda equina syndrome following a lumbar puncture

Lumbar puncture (LP), a common diagnostic procedure, is usually associated with low morbidity. We describe the case of a 29-year-old woman who underwent a non-traumatic LP in the setting of normal coagulation. Cauda equina syndrome subsequently developed secondary to an extradural spinal haematoma. Avoidance, identification and management of this uncommon complication are discussed.Iatrogenic cauda equina syndrome following LP is rare, but can cause significant morbidity. Our patient’s experience and our review of the literature highlight that: (i) normal coagulation and a non-traumatic LP do not exclude this diagnostic possibility; (ii) early recognition determines the management and prognosis, as 50% of patients remain paraplegic if the condition is identified more than 12 hours after symptom onset; and (iii) neurosurgical intervention can be avoided, despite bladder dysfunction, if there are early signs of recovery.     

Reports Arachnoiditis in the Cauda Equina Syndrome of Longstanding Ankylosing Spondylitis

A patient with cauda equina syndrome from long-standing ankylosing spondylitis exhibited erosive cystic defects of the thecal sac on lumbosacral magnetic resonance imaging. This report confirms the presence of nerve root clumping described previously, documents contrast enhancement of the leptomeninges for the first time, and suggests that arachnoiditis has a role in the evolution of this disorder.     

Coexistence of multiple sclerosis and ankylosing spondylitis: Report of four cases from Russia and review of the literature

Multiple sclerosis is a chronic demyelinating disorder of the central nervous system. There are many cases of multiple sclerosis – like syndrome and demyelinating disorders in systemic lupus erythematosus, Sjogren disease, Behcet disease and other autoimmune conditions. Coexistence of ankylosing spondylitis and multiple sclerosis usually is rare but in this article we report 4 Russian patients with concomitant multiple sclerosis and ankylosing spondylitis diseases. None of these patients received anti-tumor necrosis factor alpha therapy prior to diagnosis of multiple sclerosis. Pathogenesis, diagnostic and treatment challenges are discussed.     

Cauda equina syndrome due to disk herniation: Long-term functional prognosis

ObjectiveCauda equina syndrome (CES) caused by lumbar disk extrusion is classically considered an indication of urgent surgery. CES can be subdivided into CESI (incomplete CES) and CESR (complete CES with urinary retention and incontinence). This paper evaluates the long-term functional outcome of a CES cohort operated on due to disk herniation.MethodsSingle-center retrospective observational study. CES patients due to disk herniation that underwent surgery between 2000 and 2016 were included in the study. Demographic data, time intervals to diagnosis and surgery, preoperative neurologic status and outcome at the end of follow up were recorded.ResultsTwenty-two patients were included (median age 44 years). Eight patients were CESR and 14 CESI. Median time from symptom onset to diagnosis was 78 h (range, 12–720 h), and from diagnosis to surgery 24 h (range, 5–120 h). Median follow up was 75 months (range, 20–195 months). At the end of follow up, in the CESR group (median time from diagnosis to surgery, 23 h) only pain significantly improved after surgery (p = 0.007). In the CESI group (median time from diagnosis to surgery 23 h) low back pain, sciatica and urinary sphincter function significantly improved (p < 0.001). There were no significant differences between early (<48 h) operation (n = 4) and late (n = 18) in terms of sphincter recovery (Fisher's Exact Test, p = 0.076).ConclusionPain associated to CES improved both in the CESI and CESR groups. However, urinary sphincter impairment significantly improved only in the CESI group. No significant differences were found regarding long-term functional outcome between early and late surgery.     

Motor nerve conduction study in cauda equina with high-voltage electrical stimulation in multifocal motor neuropathy and amyotrophic lateral sclerosis

In this study we aim to establish a motor nerve conduction study (NCS) for the cauda equina and examine its usefulness in multifocal motor neuropathy (MMN) and amyotrophic lateral sclerosis (ALS). NCS of the tibial nerve proximal to the knee was performed with an optimized high-voltage electrical stimulation (HV-ES) method in 21 normal subjects, 5 with MMN, and 11 with ALS. HV-ES, but not magnetic stimulation, could supramaximally stimulate the cauda equina. Cauda equina motor conduction time determined by HV-ES, but not that with F-waves, correlated well with cauda equina length on magnetic resonance imaging. HV-ES revealed proximal lesions in 4 MMN patients but in none of the ALS patients. Importantly, 1 patient with "MMN without conduction block (CB)" had a CB in the cauda equina. Cauda equina motor conduction is better evaluated by HV-ES than with F-wave study or magnetic stimulation. HV-ES can help to distinguish MMN and "MMN without CB" from ALS.     

Cauda equina syndrome secondary to long-standing ankylosing spondylitis

Fourteen patients with cauda equina syndrome secondary to long-standing ankylosing spondylitis are described. The roughly symmetrical neurological deficits were very slowly progressive and began long after the onset of the spondylitis, usually well after the rheumatological symptoms had stopped. Eventually every patient had cutaneous sensory loss in the fifth lumbar and sacral dermatomes. All patients developed urinary sphincter disturbances of a lower motor neuron type. There was prominent loss of rectal sphincter tone, and all but 2 patients had bowel complaints, including incontinence and severe constipation. Seven patients had mild to moderate weakness in the lumbosacral myotomes. Seven patients had pain in the rectum or lower limbs. Electromyographic abnormalities were consistent with multiple lumbosacral radiculopathies. Myelography and computed tomographic scanning of the lumbosacral spine showed characteristic enlargement of the caudal sac and dorsal arachnoid diverticula that had eroded the laminae and spinous processes. Recognition of this syndrome, coupled with computed tomographic scanning of the lower spinal canal, allows one to omit myelography, a procedure that is difficult because of the associated spine abnormalities. Surgical intervention should be avoided.