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.     

Minimally invasive compared to open microdiscectomy for lumbar disc herniation

Before the advent of minimally invasive surgery for microdiscectomy, an open microdiscectomy had been the standard surgical intervention. Minimally invasive techniques have recently become more popular based upon the premise that smaller, less traumatic incisions should afford better recovery times and outcomes. From 2005 to 2008 we analyzed the outcomes of 25 patients who received an open microdiscectomy compared to 20 patients who received a minimally invasive microdiscectomy by the senior author (DC) in the lumbar region for disc herniation. A retrospective analysis was performed by carefully reviewing medical records for perioperative and immediate postoperative outcomes, and clinical follow-up was obtained either in the clinic or by telephone. There were no statistically significant differences between the minimally invasive and open groups in terms of operative time, length of stay, neurological outcome, complication rate, or change in pain score (pain improvement).     

Cauda equina compression syndrome in a child due to lumbar disc herniation

Introduction Cauda equina syndrome with sphincter dysfunction is an uncommon and feared complication of lumbar disc herniation.Case report Lumbar disc disease in the pediatric age has been reported infrequently, but to the best of our knowledge, this is the first pediatric case of acute lumber disc herniation presenting with caudal compression.     

The minimally invasive paramedian approach for foraminal disc herniation

Foraminal disc herniation presents with an operative challenge, as it often requires facetectomy, which can result in segmental instability. The intraforaminal approach includes partial pars resection and medial facetectomy and allows for direct visualization of the nerve roots and herniated disc in the foramen without violating the joint, with good clinical outcomes. Herein, we describe a retrospective series of patients that underwent minimally invasive paramedian approach with hemilaminectomy, partial medial pars resection, medial facetectomy for foraminal disc herniation. Demographics and clinical outcomes were obtained from medical records. Improvement in functional outcomes was evaluated using the pre and post-operative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). A total of 23 patients were included in this study. The average age was 56.47 ± 9.4 yrs and body mass index was 31.92 ± 7.7 kg/m². 47.8% of cases were L4-5 FDH. The estimated blood loss was 31.32 ± 19.8 ml. The average length of hospital stay was 1.11 ± 0.3 days. All patients were discharged home. Overall, there was a significant improvement in the VAS (pre-op: 8.21 ± 2.1; post-op: 2.59 ± 2.7; p-value: <0.0001) and ODI (pre-op: 57.16 ± 13.2; post-op: 21.47 ± 9.9; p-value: <0.0001). The minimally invasive paramedian approach provides satisfactory outcomes as a safe strategy in the treatment of foraminal disc herniation. Herein, there was a significant improvement in pain and functional outcomes, minimal blood loss and decreased hospital stay.     

Disseminated enteropathy-type T-cell lymphoma: cauda equina syndrome complicating coeliac disease

A patient with coeliac disease developed a progressive cauda equina syndrome in the 2 months prior to his death, for which no cause could be identified. At post-mortem examination this proved to be due to disseminated enteropathy-type T-cell lymphoma. Although rare, disseminated enteropathy-type T-cell lymphoma should enter the differential diagnosis in any patient with coeliac disease developing new neurological signs.     

Postoperative spinal adhesive arachnoiditis presenting with hydrocephalus and cauda equina syndrome

To our knowledge, the association between hydrocephalus and postoperative spinal adhesive arachnoiditis (SAA) has never been reported. Herein we describe an unusual case of a 45-year-old man with spinal adhesive arachnoiditis (SAA) who developed delayed-onset hypertensive hydrocephalus and cauda equina syndrome (CES) after multiple low-back surgeries. The patient's clinical presentation, imaging findings, surgical management, and the possible mechanisms are discussed in the light of the present literature.     

Cerebrospinal fluid dissecting into spinal epidural space after lumbar puncture causing cauda equina syndrome: review of literature and illustrative case

Objects We report a case of epidural cerebrospinal fluid (CSF) leak after lumbar puncture caused by CSF dissecting into the spinal epidural space. The incidence of this phenomenon may be higher than suspected, although most cases may remain asymptomatic. Materials and methods A 4-year-old girl with new-onset seizure underwent a diagnostic lumbar puncture, the results of which were normal; 3 h later, she began experiencing severe low-pressure headaches and lower back pain, bilateral lower extremity weakness, numbness, and pain, and urinary retention when upright. Spinal MRI demonstrated extensive epidural CSF collection posterior to the thecal sac extending from the cervicothoracic junction to the sacrum. After 48 h in the supine position and gradual mobilization, the patient had complete resolution of symptoms and no neurological sequelae. Conclusion Patients usually recover without any neurological deficits after conservative treatment. Prone or lateral decubitus positioning immediately after lumbar puncture may decrease the incidence of this phenomenon.     

Chronic inflammatory demyelinating polyradiculoneuropathy presenting as cauda equina syndrome in a diabetic

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) may occur in association with diabetes mellitus (DM). We report a case of a poorly controlled diabetic patient who presented with rapid onset of bilateral lower extremity weakness and sensory loss associated with sacral and posterior thigh paresthesias and urinary and bowel incontinence, indicative of cauda equina syndrome (CES). Subsequent evaluation was consistent with CIDP. Monthly infusions with intravenous immunoglobulins (IVIg) with strict glycemic control using insulin resulted in remarkable clinical and electrophysiological recovery. This case report describes a rare presentation of CIDP and emphasizes the importance of early utility of electrodiagnostic (EDX) studies in the clinical evaluation of diabetic patients presenting with rapidly progressive lower extremity weakness and sensory loss associated with diminished reflexes.     

Angiotropic lymphoma (intravascular large cell lymphoma) presenting with cauda equina syndrome

A 50-year-old man developed cauda equina syndrome of unknown etiology that was stable for 20 months. Two months prior to sudden death, he experienced new back pain, confusion, seizures, and multiple cranial nerve palsies. Neuropathologic examination revealed angiotropic lymphoma without parenchymal involvement or infarcts in the brain, spinal cord, and muscle. In addition, nerve roots in the cauda equina contained angiotropic lymphoma and infarcts of various ages. Angiotropic lymphoma should be considered as a cause of cauda equina syndrome and of disorders that affect the central and peripheral nervous systems concurrently.     

Solitary localised hypertrophic neuropathy of the cauda equina

Localised hypertrophic neuropathy (LHN) is an uncommon non-neoplastic lesion, which is rare in the central nervous system. We report a patient with LHN of the cauda equina. Pre-operatively these lesions cannot be differentiated from schwannoma or other benign tumours or expansions of the nerve roots. Treatment is generally surgical, largely to confirm the diagnosis, and examination of the surgical specimen reveals an expansion of the nerve by “onion bulb” whorls of Schwann cells (S-100 positive). Multiple lesions may be associated with the generalised diffuse hypertrophic neuropathies or chronic inflammatory demyelinating polyneuropathies. It should be differentiated from intraneural perineuroma, which has a similar appearance but comprises perineural cells (epithelial membrane antigen positive). Adjuvant therapy is not required.     

Post-hemorrhagic hydrocephalus presenting as cauda equina syndrome in a patient with spinal dysraphism

Hydrocephalus has varied presentations in patients with a history of spinal dysraphism. This is a unique case of post-subarachnoid hemorrhage hydrocephalus presenting as cauda equina syndrome. We report on a 32-year-old woman with remotely repaired spinal defect who experienced subarachnoid hemorrhage and underwent anterior communicating artery aneurysm clipping. Post-operatively, she developed urinary and fecal incontinence as the sole presenting symptom of communicating post-hemorrhagic hydrocephalus. New neurological deficits in this population can also be attributed to recurrent cord tethering or syrinx, both of which were demonstrated on her lumbar spine MRI, but her incontinence resolved with external ventricular drain placement and cerebrospinal fluid diversion. There are few case reports of patients with closed neural tube defects and hydrocephalus and none in the adult population to our knowledge. Neurological change in patients with any history of spinal dysraphism may reflect altered cerebrospinal fluid dynamics affecting either end of the neuraxis.     

腰椎间盘突出症并马尾神经综合征的外科治疗

目的 探讨腰椎间盘突出征并马尾神经综合征的临床特点和外科手术治疗效果.方法 回顾分析我们科室在2000-2010年收治的42例腰椎间盘突出症并马尾神经综合征的临床资料,腰椎间盘突出症并马尾神经综合征的患者占同期收治的腰椎间盘突出症680例的6.17%.全部急诊手术治疗,其中13例采用半椎板摘除术,5例全椎板摘除术,24例有限全椎板采用椎弓根内固定椎间融合器固定加后外侧植骨术.所有患者手术后均应用激素.结果 手术后随访半年到3年,平均1.5年,所有小便失禁得到恢复,鞍区感觉不同程度恢复.结论 腰椎间盘突出症并马尾神经综合征的患者应该在明确诊断后急诊手术治疗,根据其骨质和椎管的情况选择合理的手术方式,围手术期应用激素治疗可以起到较好的疗效.     

Sarcoidosis of the cauda equina: a report of three cases

Summary Three cases of sarcoidosis of the cauda equina are presented. In two there was no previous history suggestive of sarcoidosis and the presentation was one of a painful flaccid paralysis; in these the diagnosis was made after myelography and laminectomy with subsequent histology. The third patient had a previous diagnosis of lupus pernio and magnetic resonance imaging (MRI) was used to aid diagnosis. Only two previous cases have been reported of sarcoidosis presenting in the cauda equina with no other systemic manifestations. This is the first report of the use of MRI in sarcoidosis of the lower meninges.     

Tumors of the cauda equina: the importance of an early diagnosis

The natural history of cauda equina tumors was studied in 13 patients. Pain was the most prominent clinical manifestation. Neurological dysfunction mainly consisted of sensory disturbances. The pre-operative course was in 62% three years or longer.

A relation was found between the histology of the tumor and the delay of diagnosis: ependymomas were discovered much later than schwannomas. Other histological types of tumors were meningioma, sarcoma and metastasis of a medulloblastoma.

The effect of treatment, in nine cases only surgical, was excellent in seven of the 13 patients.

The prognosis was determined by histology and length of pre-operative period.     

微创翻修治疗复发性腰椎间盘突出症(附39例报告)

目的探讨微创翻修治疗复发性腰椎间盘突出症的疗效及复发的相关因素。方法 2008年1月至2010年10月采用微创翻修治疗复发性腰椎间盘突出症39例,其中显微内镜下微创翻修28例,应用Quadrant系统行椎间融合术微创翻修11例,同时分析腰椎间盘突出症复发的相关因素。术后随访11～38个月,平均(16.4±2.6)个月,通过影像学资料和末次随访时的临床表现进行Nakano标准疗效评定。结果依据Nakano标准评定疗效,39例患者中,优24例,良13例,中1例,差1例;优良率94.9%(37/39)。结论初次手术处理不当、神经压迫未完全解除以及术后腰椎局部生物力学的改变是腰椎间盘突出复发的主要原因;再次手术治疗复发性腰椎间盘突出症,应解决致压物或同时解决减压和稳定两个问题;选用微创翻修避开原手术切口的瘢痕组织,减少神经损伤和脑脊液漏等并发症,手术出血少,术后恢复快,可获得良好的效果。     

Tumors in the cauda equina: A SEER analysis of tumor types and predictors of outcome

Cauda equina tumors are histologically diverse. International Classification of Diseases for Oncology (ICD-O3) confers dedicated site code (C72. 1) for cauda equina. This code is excluded during analyses of other primary spinal cord tumors. In this retrospective study, the Surveillance, Epidemiology and End Results (SEER) data for primary cauda equina tumors (PCET, C72. 1) excluding the tumors of spinal meninges (C70. 1) from 1992 to 2015 were reviewed. Demographic characteristics, tumor types, and clinical outcomes were analyzed using univariable analysis. Overall survival was estimated using Kaplan-Meier methods and compared for age, histology and treatment type. 293 patients with PCET met inclusion criteria. The most common tumors comprised schwannoma (32%), myxopapillary ependymoma (21%), malignant ependymoma (22%). The median age at diagnosis was 50 years (range < 1 year to 98 years), 57% of patients were males. 77% of the patients underwent surgery. Median follow up time for these patients was 70 months. Of the 293 patients, 250 (85%) were living at the end of 2015. The cause of death was tumor or CNS related in 15 patients. 136 patients were followed for <5 years, of which 102 were censored and 34 died (11.6%) before 5 years. Using univariable analysis, age at diagnosis (Hazard Ratio, HR 1.05; confidence interval, CI 1.03–1.07; p < 0.001), malignant tumor type (HR 2.88, CI 1.15–7.19, p = 0.0239) and absence of surgical intervention (HR 2.54, CI1.26–5.11, p = 0.0092) were predictors of increased mortality. Although most patients did well, older age and lack of surgical intervention were associated with worse survival.     

T2-SPACE imaging of the cauda equina for the assessment of leptomeningeal metastatic disease

The diagnosis of leptomeningeal metastatic disease (LMD) is frequently challenging and MRI of the spine is an important part of the diagnostic paradigm. We sought to examine the value of adding 3-dimensional, heavily T2-weighted, Sampling Perfection with Application optimised Contrasts using different flip angle Evolution (T2-SPACE) imaging of the lumbar spine to the MRI protocol for patients with suspected LMD. MRI spine examinations including T2-SPACE imaging of the lumbar spine performed for suspected or known LMD were retrospectively reviewed by a neuroradiologist to determine the additional benefit of the T2-SPACE sequence. The accuracy of T2-SPACE was also compared to contrast-enhanced T1-weighted imaging (ceT1WI) and standard T2-weighted imaging (T2WI). 59 patients with T2-SPACE were identified over a 20-month period, 17 having abnormal appearances on ceT1WI, including 12 with appearances consistent with LMD. In eight of these 12 patients, nodules visible on T2-SPACE were visible on T2WI, though T2-SPACE improved the temporal comparison of slowly progressive cauda equina nodules in two cases. In three patients, T2-SPACE identified nodules which were not readily identifiable on T2WI, though were visible on ceT1WI. In one patient, LMD visible on ceT1WI was not appreciable on T2-SPACE or T2WI due to the lack of a nodular component. In six patients, T2WI showed equivocal nodularity, which could be confidently attributed to facet joint arthropathy or a tortuous vessel. In conclusion, T2-SPACE has high sensitivity and specificity for the detection of nodular lesions of the cauda equina and can confidently characterise equivocal findings on standard T2WI.     

Metastatic malignant peripheral nerve sheath tumor of the cauda equina

Malignant peripheral nerve sheath tumor (MPNST) of the cauda equina is rare, with only four reported patients in the literature. We present a 70-year-old woman with a history of left sciatic nerve MPNST that had been treated by left hemipelvectomy 4 years prior. She then presented with disabling right leg weakness that progressed over 7 months. Spine imaging revealed an intradural extramedullary lesion from L5 to S1 with compression of the cauda equina. She underwent an L3-S1 laminectomy with subtotal resection of the lesion, which was diagnosed as a metastatic MPNST. At the 3-month postoperative visit, her lower extremity strength had returned to baseline. The only notable postoperative complication was a superficial wound infection that resolved with antibiotic treatment and wet-to-dry dressing changes. Thus, although uncommon, the spinal canal and cauda equina should be considered as possible locations for metastatic MPNST in the appropriate clinical scenario. To our knowledge, this is the first report of a patient with a metastatic MPNST to the cauda equina.