Cauda equina syndrome

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. 

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)... 

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 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. 

Loo CC, Irestedt L. Cauda equina syndrome after spinal anaesthesia with hyperbaric 5% lignocaine a review of six cases of cauda equina syndrome reported to the Swedish Pharmaceutical Insurance 1993-1997. Acta Anaesthesiol Scand 1999 43(4) 371-9. 

Tetzlaff JE, Dilger J, Yap E, Smith MP, Schoenwald PK. Cauda equina syndrome after spinal anaesthesia in a patient with severe vascular disease. Can J Anaesth 1998 45(7) 667-9. 

Lee DS, Bui T, Ferrarese J, Richardson PK. Cauda equina syndrome after incidental total spinal anesthesia with 2% hdocaine. J Chn Anesth 1998 10(l) 66-9. 

Kubina P, Gupta A, Oscarsson A, Axelsson K, Bengtsson M. Two cases of cauda equina syndrome following spinal-epidural anesthesia. Reg Anesth 1997 22(5) 447-50. 

Akioka K, Torigoe K, Maruta H, Shimizu N, Kobayashi Y, Kaneko Y, Shiratori R. A case of cauda equina syndrome following spinal anesthesia with hyperbaric dibucaine. J Anesth 2001 15(2) 106-7. 

Note the neurological complications in the complete spondyloptosis Cases 9 and 15. These cases were reduced and developed cauda equina syndrome postoperatively and had to be unreduced. They both recovered their neurologic loss. 

In situ fusion without decompression is supposed to be efficient thanks to the stabilising effect of fusion without the neurological risk of decompression. In fact, cauda equina syndromes have been described, even after a postero-lateral fusion only. 

Honet JC, Ellenberg MR (1990) Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbo-sacral junction. J Bone Joint Surg 73 369-377... 

From a combination of personal communications with the treating surgeons and a literature review, it appears that one common complication of attempting to reduce L5 onto SI for patients with spondyloptosis is postoperative L5 nerve root deficit. An additional more serious, but commonly described, complication is iatrogenic cauda equina syndrome with loss of... 

Because of personal experience with iatrogenic L5 nerve root injury and iatrogenic cauda equina syndrome, during attempted anatomic reduction of L5 onto SI, the two stage procedure with L5 resection and reduction of L4 onto SI was developed in 1979 to avoid spinal lengthening (Fig. 5). 

In the last twenty years, 27 of these procedures were performed for severely functionally handicapped patients. No patients without severe symptoms were operated. Twenty-one of the patients had had no previous surgery. Six had had multiple previous attempts to achieve stabilization, reduction and decompression for very severe disability. Most of them had had pre-operative or post-operative cauda equina syndrome as well as L5 nerve root deficit. 

One multiply operated patient who had pre-operative cauda equina syndrome twice, does wear a bilateral drop foot brace for L5 nerve root deficit though she no longer takes any narcotic medication. She was deeply habituated on narcotics prior to the surgical procedure. 

Nervous system A healthy elderly man developed a cauda equina syndrome after combined spinal and epidural anesthesia with hyperbaric bupivacaine [55 ]. He had no pre-existing neurological condition and there were no technical problems. 

Intrathecal liposomal cytarabine can cause seizures, encephalitis, and cauda equina syndrome. The risk is increased in patients treated with concurrent systemic methotrexate and cytarabine [17 ]. 

This is the first report of cauda equina syndrome induced by procaine. The relative risk compared with other local anesthetics needs to be established. 

Chabbouh T, Lentschener C, Zuber M, Jude N, Delaitre B, Ozier Y. Persistent cauda equina syndrome with no identifiable facilitating condition after an uneventful single spinal administration of 0.5% hyperbaric bupivacaine. Anesth Analg 2005 101 (6) 1847-8. 

There are many other manifestations of neurosarcoidosis. Probably one of the most underappreciated of these is spinal sarcoidosis. Patients may present with transverse myelopathy, autonomic dysfunction, paresis, radicular syndrome, and cauda equina syndrome (146,159,160). Sarcoidosis may cause a peripheral neuropathy (143,150), Guillain-Barre syndrome (146,150,161,162), and seizures (150,162) the presence of seizures portends a poor prognosis (146). Granulomatous infiltration of the CNS from... 

A posterolateral herniation is most common. In the lumbar region, the most common disc herniations occur at L5-S1 or L4-L5. These account for approximately 95% of all lumbar disc herniations. Most serious is the impingement of the cauda equina in the lower spinal canal or the spinal cord at a higher level leading to cauda equina syndrome. Bowel and/or bladder dysfunction, paresis, or paralysis may result... 

A prospective randomised double-blind controlled trial comparing lidocaine and chloroprocaine for outpatient transurethral prostatectomy yielded similar clinical end points (primary end point duration of spinal block) [36 ]. Four patients in the lidocaine group developed TNS and one patient in the chloroprocaine group developed an acute cauda equina syndrome, which fully recovered after several weeks. Based on this, the authors conclude that they cannot recommend lidocaine in view of the high incidence of TNS and recommend close follow-up for chloroprocaine to ensure its safety profile. 

A case of epidural lipoedema causing cauda equina syndrome after lumbar spine decompression and fusion with BMP-2 developed in a 45-year-old woman. Progressive cauda equina syndrome developed 2 days postoperatively. The acute nature and rapid development of lipedaemia and accumulation of oedematous tissue indicated an intense inflammatory reaction and a possible link wi the BMP used as an adjunct for arthrodesis [9 ]. 

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