Cauda equina

Molla MAR, Harrison JE, McNeill KG. 1976. Doses to the cauda equina due to Thorotrast myelography. Health Phys 31 109-114. 

Glucocorticoids given intrathecally can cause a rise in cerebrospinal fluid protein and carry the risk of arachnoiditis (SED-8, 820). Chemical meningitis has been reported after two intrathecal injections of methylpredni-solone acetate (450) and after lumbar facet joint block (SEDA-17, 450). Intraspinal injections of hydrocortisone for multiple sclerosis apparently led in one case to a cauda equina syndrome, with subsequent ulceromutilating acro-pathy (SEDA-17, 450). Intra-discal injections of triamcinolone acetonide in a number of French cases led to disk or epidural calcification, sometimes symptomless (SEDA-17, 450). 

One case of Staphylococcus aureus meningitis, a rare complication of epidural analgesia, has been published. The same patient developed a cauda equina syndrome of uncertain etiology, although neural ischemia as a result of meningitis secondary to immunosuppression was possible (SEDA-21,420 456). A unique case of transient profound paralysis after epidural glucocorticoid injection (acute paraplegia) has now been reported (SEDA-22, 451 457). Diplopia associated with the peridural or intrathecal infiltration of prednisolone have not been previously reported (SEDA-22, 451 458). 

Cooper AB, Sharpe MD. Bacterial meningitis and cauda equina syndrome after epidural steroid injections. Can J Anaesth 1996 43(5 Part l) 471-4. 

Dissect the vertebral column. Note the cell bodies of lumbar motor neurons are more rostral than their exit points, i.e., L4 cells bodies are in upper lumbar or even lower thoracic vertebrae, even though the spinal nerve exits at the fourth lumbar vertebrae. The more caudal vertebral column contains only the cauda equina, the dorsal, and ventral roots of lower lumbar and sacral motor neurons (Fig. 20.2). 

Fig. 20.2. The spinal cord and cauda equina. The caudal spinal cord does not completely fill the caudal vertebral column. As a result, the dorsal and ventral roots of lumbar and sacral neurons are very long, spanning from the more rostral cell bodies to the more caudal exit points. Therefore, the dissected spinal cord resembles a horse s tail. The practical effect of this anatomy is that it becomes very hard to reliably determine the level of the spinal cord that is being studied in any given cross-section.

Since there is always a potential risk that epidural leakage of chymopapain from the disk space will occur, there iB a chance that other tissues, such as epidural fat, dura, and local nerve endings, will be exposed to proteolytic enzyme. A number of neurological complications hove been described, including subarachnoid hemorrhage [90], paralysis, and cauda equina compression syndrome [91]. 

In most cases of the thoracolumbar infarction, the swollen cord shows peripheral enhancement of the central gray matter. The concomitant enhancement of the cauda equina was reported first by Friedman and Flanders in 1992 (Fig. 17.8). This phenomenon is a characteristic finding in the course of spinal cord ischemia which might involve the cord itself and the ventral cauda equina as well, which is composed of motor fibre bundles (Amano et al. 1998). It indicates disruption of the blood-cord barrier as well as reactive hyperemia (Friedman and Flanders 1992 Amano et al. 1998). The differential diagnosis of contrast enhancement of the cauda equina includes transverse myelitis, bacterial or viral meningitis, and spinal metastasis. 

Fig. 17.8a,b. Acute ischemic myelomalacia of the lumbar enlargement 3 weeks after onset of symptoms. Contrast-enhanced Tl-weighted images in sagittal and axial orientation at different levels, a Enhancement of the ventral cauda equina (arrow, arrowhead), b Peripheral ring-like enhancement of the affected lumbar enlargement (arrow, arrowhead)... 

Amano Y, Machida T, Kumazaki T (1998) Spinal cord infarcts with contrast enhancement of the cauda equina two cases. Neuroradiology 40 669-672... 

Spiller W (1909) Thrombosis of the cervical anterior median spinal artery. I Nerv Ment Dis 36 601 Stein SC, Ommaya AK, Doppman JL, Di Chiro G (1972) Arteriovenous malformation of the cauda equina with arterial supply from branches of the internal iliac arteries. Case report. J Neurosurg 36 649-651 Stepper F, Lovblad KO (2001) Anterior spinal artery stroke demonstrated by echo-planar DWI. Eur Radiol 11 2607-2610 Suh T.H., Alexander L (1939) Vascular system of the human spinal cord. Arch Neurol Psychiat 41 659-677 Suzuki T, Kawaguchi S, Takebayashi T, Yokogushi K, Takada J, Yamashita T (2003) Vertebral body ischemia in the posterior spinal artery syndrome case report and review of the literature. Spine 28 E260-264... 

Ogawa-Goto K, Funamoto N, Ohta Y, Abe T, Nagashima K (1992) Myelin gangliosides of human peripheral nervous system An enrichment of GMl in the motor nerve myelin isolated from cauda equina. J Neurochem 59 1844—1849. 

Alkylosiiig spondylitis Interver tebral joints and sacroiliac jomt Eye hiflammations and caudae equinae related nemopatliies... 

Alkylosing spondylitis Intervertebral joints and sacroiliac joint Eye inflammations and caudae equinae related neuropathies... 

Cauda equina syndrome has been reported after a spinal anesthetic using cinchocaine (2). 

A 64-year-old man with a history of borderline diabetes who had undergone two previous operations uneventfully under spinal anesthetic received a spinal anesthetic with hyperbaric 0.24% dibucaine 2.2 ml and then a general anesthetic because of unilateral block. The next day he complained of difficulty in defecation and urination, with abnormal anal sensation. A diagnosis of cauda equina syndrome was made. He made a gradual recovery, but mild hypesthesia remained after 4 months. 

Yorozu T, Matsumoto M, Hayashi S, Yamada T, Nakaohji T, Nakatsuka I. [Dibucaine for spinal anesthesia is a probable risk for cauda equina syndrome.jMasui 2002 51(10) 1151-4. 

A systematic review of all prospective studies of the risks associated with spinal manipulation included five primary investigations (150). The most valid studies suggested that about half of all patients who see a chiropractor will have adverse effects, which are usually mild and transient. No reliable data about serious adverse events were uncovered. However, a review of recent case reports has shown that spinal manipulation was associated with several serious adverse effects, including dissection of the vertebral and internal carotid arteries, resulting in strokes and at least one death (151). Other instances relate to epidural hematoma, intracranial aneurysm, cauda equina syndrome, contusion of the spinal cord, myelopathy, radiculopathy, and palsy of the long thoracic nerve. 

Back pain Cauda equina syndrome Lumbar Traditional healer Likely (172)... 

Balblanc JC, Pretot C, Ziegler F. Vascular complication involving the conus medullaris or cauda equina after vertebral manipulation for an L4-L5 disk herniation. Rev Rhum Engl Ed 1998 65(4) 279-82. 

Four cases of cauda equina syndrome have been described with methylglucamine iocarmate used for radiculography, although in two cases faulty technique was perhaps contributory. 

Cauda equina syndrome is the triad of bilateral paraparesis or paraplegia of the muscles of the legs and buttocks, saddle anesthesia plus sensory deficits below the groin, and incompetence of bladder and rectal sphincters, causing incontinence of urine and feces. 

Cauda equina syndrome has been reported after the use of microcatheters for continuous intrathecal anesthesia. The concern was sufficient reason for the FDA to withdraw microcatheters from the US market after 11 cases of cauda equina in 1992 (SEDA-21, 129) (206). It has now become obvious that a confounding factor was the use of hyperbaric solutions pooling around lumbosacral nerve roots, aggravated by the poor mechanics of microcatheters and the use of inappropriate amounts the authors of one study argued that the problem was not evident with the use of low concentrations of isobaric local anesthetics administered via microcatheters (207). 

A 57-year-old man with pre-existing severe vascnlar disease was given bupivacaine 12.5 mg with 1 1000 adrenaline 0.2 ml for incision and drainage of a thigh abscess (211). After 2-3 minutes he complained of severely painful warmth on the anterior of both thighs. The pain resolved with onset of the block, bnt the next morning he had symptoms of cauda equina sjmdrome. Some perineal sensation returned over the next few days. 

A man with severe vascular disease was given general and epidural anesthesia with 2% isobaric hdocaine plus adrenaline for a popliteal distal vein bypass graft (212). The epidural inadvertently became a total spinal, which was discovered at the end of the operation. He developed cauda equina syndrome, confirmed by electromyography. He was unable to tnm or sit np by himself for a month and at 12 months was walking with a cane and needed self-catheterization and medication for neuropathic pain. 

Bupivacaine has recently been implicated in two cases of cauda equina syndrome (213). One patient was given 3.6 ml of a hyperbaric 0.5% solution, and the other, 3.5 ml of plain bupivacaine. Spinal stenosis was felt to have contributed to the first case, while the cause of the second was unclear. 

Cauda equina syndrome occurred in a 55-year-old woman who underwent spinal anesthesia with a 22 G needle in the L4-5 interspace (214). On needle insertion, she felt radiating pain in her right leg. The needle was immediately withdrawn and repositioned. Pain-free intrathecal injection of 2.0 ml of hyperbaric cinchocaine 0.24% with adrenaline 66 micrograms resulted in block to LI. Surgery was carried out in the supine position. Three days postoperatively, she had enuresis and reduced perineal sensation, without bowel dysfunction or lower limb symptoms. There was sensory loss at S2-5. The symptoms persisted, required self-catheterization and systemic steroids, and disappeared on the 19th postoperative day. 

Benson JS. U.S. Food and Drug Administration safety alert cauda equina syndrome associated with use of small-bore catheters in continuous spinal anesthesia. AANA J 1992 60(3) 223. 

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