[Bruns Garland syndrome. Report of a case and differential diagnosis with cauda equina syndrome]

BACKGROUND

The Bruns Garland syndrome (diabetic amyotrophy) it is a very rare condition, with few cases reported in the literature. Clinical differentiation of diabetic amyotrophy or cauda equine syndrome may be difficult. The issue of misdiagnosis has been discussed as a reason for poor outcome after lumbar spine surgery. We report a case of diabetic amyotrophy that mimics a cauda equina syndrome.

CASE DESCRIPTION

A 59 years old man diabetic patient that suddenly begins with weakness of lower extremities and loss of sphincters control. The patient was seen in the emergency room, the anteroposterior and lateral radiographs of the lumbosacral spine evidenced spondylolisthesis L5-S1 level II of Meyerding. However, the MRI show no vertebral canal compression, nerve root compression or disc extrusion. Electrodiagnostic study revealed diabetic amyotrophy (Bruns Garland syndrome). The patient rapidly improves with treatment based in antineuritics, diabetes control, physical therapy and rehabilitation. Four months after the diagnosis he recover his muscle strength, has no alterations in the march, no loss of balance, his sensitive is preserved and has no pain.

CONCLUSION

Electrodiagnostic and radiologic studies should be used in every diabetic patient presenting with leg pain and/or weakness to differentiate diabetic neuropathy from cauda equina syndrome. Treatment of both diseases may be needed for relief of the patients pain.

[Surgical treatment of intramedullary-extramedullary ependymomas. Two clinical cases and a literature review]

Ependymoma is a central nervous system tumor that grows from ependymal cells lining the cerebral ventricles, central canal of the spinal cord, and filum terminale. Regardless of the histological type of ependymomas, they rarely have exophytic growth. Because of an extremely low occurrence rate of this phenomenon, we present two clinical cases of patients with classical intramedullary ependymomas (Grade II) having an extramedullary component.

MATERIAL AND METHODS

The paper presents two clinical cases of patients with intramedullary-extramedullary ependymomas of the spinal cord. The surgical technique is described. After surgical treatment, the performance status of patients remained unchanged.

CONCLUSION

Radical removal of complex ependymomas provides conditions for long-term disease-free survival and further neurological recovery.

Cauda equina involvement in post-radiation lower motor neuron syndrome

Post-radiation lower motor neuron syndrome (PRLMNS) is a rare neurological complication of radiation therapy and its pathogenesis is unclear. We herein report a patient with PRLMNS who developed leg weakness 17 years after craniospinal radiation as a treatment for suprasellar germinoma. The electrophysiological evaluation, via a novel magnetic stimulation method, indicated a prolonged cauda equina conduction time, suggesting focal demyelination of the nerve roots in the cauda equina. The distribution of the denervated muscles detected by magnetic resonance imaging was consistent with patchy motor nerve root lesions. These results support the hypothesis that PRLMNS originates from ischemic radiculopathy in the cauda equina.

Paraganglioma in the cauda equina. A case report

Paraganglioma of the cauda equina is rare, and diagnosis is difficult. A 47-year-old woman presented with backache, with a 2-year history of pain radiating in her right lower extremity. Initial neurologic examination revealed mild hypaesthesia in the L4 dermatome on both sides. Spine MRI showed a well-delinated intradural extramedullary mass compressing the spinal cord. It extended from L2 to L4, with anterior compression of the spinal cord which was displaced posteriorly. Clinical and radiological findings suggested an ependymoma. Surgical decompression was performed from L2 to L4 through lumbar laminectomy under microscope. Intraoperatively, the patient experienced unexplained paroxysmal hypertension while manipulating the tumour, which was not relieved by hypotensive medication but resolved immediately after resection of the mass. Postoperatively, the neurologic status improved and the radiating pain was relieved. Histopathologic examination showed cellular perivascular arrangement which looked like 'pseudorosettes'. Taken together, these histologic and radiologic findings suggested a benign myxopapillary ependymoma. However, immunohistochemical examination showed reactivity with synaptophysin and chromogranin. Finally, histological examination of the specimen revealed a 'Zellballen' pattern of paraganglioma, and the final diagnosis of paraganglioma with secreting function was confirmed. Paraganglioma is a rare tumour that can exhibit a secreting function causing paroxysmal hypertension which may be life threatening. Therefore, the differential diagnosis is important. The diagnosis is based on close examination of the clinical, radiologic and pathologic findings.

Surgical treatment of spinal intradural carcinoma metastases

BACKGROUND

Intradural metastases of nonneurogenic origin represent an extremely rare manifestation of systemic cancer. The respective literature is very scarce.

METHODS

We retrospectively evaluated nine patients with intradural metastases treated surgically from March 2006 until today at our department.

RESULTS

Four metastases were intramedullary and five intradural extramedullary. Localisation along the spine involved: cervical n = 3, thoracic n = 3, and conus/cauda n = 3. Five patients were female and four male, with a median age of 71 years. Histology showed: breast cancer n = 2, NSCLC (non-small cell lung cancer) n = 2, SCLC (small cell lung cancer) n = 1, colon carcinoma n = 1, malignant skin melanoma n = 1, squamous cell carcinoma of the skin n = 1, and ovarian carcinoma n = 1. Holospinal dissemination in terms of leptomeningeal carcinomatosis according to MRI or positive CSF (cerebrospinal fluid) cytology, respectively, was found in four patients. Gross total resection was achieved in four patients and debulking in five. Results of surgical decompression were: six patients (67%) exhibited immediate improvement of neurological symptoms and/or pain; four of them even improved according to the McCormick Scale score (44%); two patients (22%) were unchanged, and one (11%) exhibited worsening of neurological symptoms after surgery. Median survival time after surgery was 7.3 months.

CONCLUSIONS

Intradural metastases are associated with limited survival time. Accordingly, the aim of surgery is strictly palliative. The majority of patients benefit with respect to neurological deficit/pain (67%) independent of the extent of resection. Thus, decompressive surgery is recommended to increase the quality of life.

Diagnosis of spinal cord compression in nontrauma patients in the emergency department

OBJECTIVES

The objectives were to evaluate the presenting signs and symptoms of spinal cord and cauda equina compression (SCC) and to determine the incidence of emergency department (ED) misdiagnosis.

METHODS

This was a retrospective chart review at an urban, tertiary care hospital of patients discharged from an inpatient stay (April 2008 through July 2009) with an International Classification of Diseases, Ninth Revision (ICD-9) code indicating spinal disease, who had visited the ED for a related complaint within the previous 30 days, and who had a final diagnosis of new SCC. Trauma and transferred patients were excluded. The authors defined a misdiagnosis as no ED-documented diagnosis of SCC and failure to perform an appropriate diagnostic study either prior to arrival, in the ED, or immediately upon admission.

RESULTS

Of 1,231 charts reviewed, 63 met inclusion criteria. The most common presenting symptoms in patients with SCC were pain (44, 70%), difficulty ambulating (38, 60%), and weakness (35, 56%). On physical examination, motor deficits (45, 71%) were more common than sensory deficits (27, 43%); however, 15 (24%) patients had no motor or sensory deficit, and 13 (23%) patients only had unilateral findings. Impaired gait was present in 14 patients of only 20 tested, three of whom had no associated motor or sensory deficit. SCC was misdiagnosed in 18 (29%, 95% confidence interval [CI] = 19% to 41%) cases, which resulted in a significant delay to diagnosis (median = 54 hours, interquartile range [IQR] = 38 to 77 vs. 5.3 hours, IQR = 3.0 to 15) in these patients.

CONCLUSIONS

SCC can have a subtle presentation with absent or unilateral motor and sensory deficits, but gait ataxia may be an additional finding. ED misdiagnosis of SCC in nontrauma patients is common.

[P75 neurotrophin receptor mRNA sequential expression and significance after Cauda equina compression in rats]

OBJECTIVE

To observe the mRNA expression of p75NTR (p75 neurotrophin receptor) and the amount of neuronal cells apoptosis in lumbar-sacral spinal cord at different time points after the acute cauda equina compression in rats and to explore their correlation.

METHODS

Sixty adult female Sprague Dawley(SD) rats were randomly divided into the normal control group and the compression groups. The acute cauda equine compression model was established as placing a silicon gel rubber at L(3,4) level of the vertebral canal which represented about 70% to 80% compression to the cross section. The whole L(1,2) level of spinal cords were harvested at 1, 3, 5, 7, 14, 28 d after operation in compression group. Tunel method was applied to observe cell apoptosis and RT-PCR was used to detect the p75NTR mRNA expression. SPSS 13.0 statistical software was adopted to help analysis.

RESULTS

In the compression group, both the nerve cells apoptosis and the p75 mRNA expression existed the trend of low-high-low synchronally compared with the control group, there was a significant difference (P < 0.05) among comprssion groups at different time points,there was a significant difference in changes (P < 0.05). p75NTR of mRNA expression and lumbosacral nerve cells apoptosis was in a positive correlation.

CONCLUSION

After acute cauda equina compression, p75NTR mRNA expression is closely related to the neuronal apoptosis, which plays an important role in the molecular mechanism of the CES.

Spinal compression by brown tumor in two patients with chronic kidney allograft failure on maintenance hemodialysis

Brown tumors with non-neoplastic process are noticed in patients with end-stage renal disease suffering from a severe form of secondary hyperparathyroidism. Herein, we report a patient with chronic kidney allograft failure returned back to hemodialysis who experienced manifestations of cauda equina compression secondary to a lumbar brown tumor. Also, we had another patient on hemodialysis with a demineralized lesion affecting the cervical vertebrae. Although brown tumor is a rare complication, these two cases highlighted the importance of neurological symptoms in uremic patients. Spinal decompression surgery, in order to alleviate pressure on neurological structures, together with subtotal parathyroidectomy, were highly indicated.

Magnetic resonance imaging of the lumbosacral spine in children with chronic constipation or non-retentive fecal incontinence: a prospective study

OBJECTIVE

To determine the prevalence of lumbosacral spine (LSS) abnormalities in children with defecation disorders, intractable constipation, or non-retentive fecal incontinence (NRFI) and evaluate whether LSS abnormalities on magnetic resonance imaging (MRI) are clinically detected by neurologic examination.

STUDY DESIGN

MRI of the LSS and complete neurologic examination by a pediatric neurologist blinded to the MRI results were performed in patients with intractable defecation disorders.

RESULTS

Patients with intractable constipation (n = 130; 76 males; median age, 11 years; range, 6-18 years), and patients with NRFI (n = 28; 18 males; median age, 10 years; range, 7-15 years) participated. One occult spina bifida (OSB) and 3 terminal filum lipomas were found in patients with a normal neurologic examination. One patient had a terminal filum lipoma and neurologic complaints. Gluteal cleft deviation was found in 3 of 4 patients with LSS abnormalities. Neurosurgical treatment was not required in any patient during the 12-week follow-up.

CONCLUSIONS

MRI showed LSS abnormalities in 3% of patients with defecation disorders and normal neurologic examination, all of whom reported symptom relief at the 12-week follow-up without neurosurgical intervention. Thus, whether or not LSS abnormalities play a role in defecation disorders remains unclear.

Outcomes in patients admitted for rehabilitation with spinal cord or cauda equina lesions following degenerative spinal stenosis

PURPOSE

To evaluate outcome measures and the factors affecting them in patients treated between 1962 and 2000 at Loewenstein Rehabilitation Hospital, Israel.

METHOD

This retrospective cohort study included 262 patients with spinal neurological lesions (spinal cord or cauda equina lesions) following degenerative spinal stenosis. Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method and the relative mortality risk by the Cox model. Neurological recovery was evaluated by the change in Frankel grades, and factors that affect it were assessed by logistic regression. Associations of length of stay in rehabilitation were analyzed with ANOVA.

RESULTS

Median age at lesion onset was 61 years and median survival 17.6 years. Age at spinal neurological lesion onset was found to be the only factor with a significant effect on survival. Of the 148 patients who had Frankel grades A, B, or C on admission, 58% achieved recovery to grades D and E. Frankel grade at admission, age, and spinal neurological level had a significant effect on recovery. The mean length of stay was 99.7 days, and only Frankel grade had a significant effect on length of stay.

CONCLUSIONS

Patients with spinal stenosis and disabling spinal neurological lesions can achieve significant neurological recovery and survive for many years. They require adequate care in a specialist rehabilitation system.

Paraganglioma of the cauda equina presenting with erectile and sphincter dysfunction

Paragangliomas of the cauda equina are rare neuroepithelial tumors, usually manifesting clinically as sciatica. Here, we report a case of cauda equina paraganglioma with an unusual course in a 43-year-old man. His main complaints were erectile and sphincter dysfunction. The low back pain was initially ascribed to accidental injury. Magnetic resonance imaging revealed intradural tumor at the L2/L3 level. The patient underwent gross tumor resection, and the diagnosis of paraganglioma was based on neuropathologic examination. The symptoms completely resolved after tumor resection.

Cauda equina tumor mimicking an intradural disc herniation, with emphasis on differential diagnosis--a case report

We report a rare case of lumbar disc prolapse with intradural schwannoma at the same level. A 33-year-old man had had moderate right leg pain for about four years, which had worsened suddenly when he lifted heavy baggage. MR imaging revealed lumbar disc prolapse at L4/5. An intradural tumor that was iso-intense on T1-weighted and slightly hyperintense on T2-weighted images was also recognized at the same level. The tumor was homogeneously enhanced on Gadolinium-MRI (Gd-MRI). Intractable back and leg pain necessitated surgical treatment, which yielded a definitive diagnosis of the intradural tumor as schwannoma on histological examination. The intractable pain disappeared immediately after surgery. The patient's intractable and prolonged pain appeared to be due to combined compression by the intradural tumor and disc prolapse. The findings of Gadolinium-MRI were helpful in making the diagnosis.

[Urodynamic analysis of the chronic impairment of cauda equina caused by lumbar disk herniation]

OBJECTIVE

To evaluate the urodynamic characteristics of the chronic impairment of cauda equina caused by lumbar disk herniation.

METHODS

Clinical data and urodynamic parameters of 67 male patients with lumbar disk herniation were retrospectively analyzed. Lower urinary obstruction was excluded from the cohort using the Lin-PURR analysis. Patients were divided into group A (normal detrusor function), group B (detrusor underactivity) and group C (detrusor areflexia) according to the detrusor contraction function analyzed in Lin-PURR. Clinical data and urodynamic parameters were analyzed statistically between these groups.

RESULTS

The category of the detrusor contraction function had a significant effect on the urodynamic parameters. There were significant differences in the maximum flow rate (Q(max)), maximum pressure (P(max)), pressure at the maximum flow (P(det Qmax)) and post-voiding residual urine (PVR) among group A, B and C. There were significant differences in the first sensation volume of the bladder and the maximum cystometric capacity between group A and C, B and C, but no significance was found between group A and B. There was no significant difference in age, disease duration, and compliance of the bladder among 3 groups.

CONCLUSIONS

Urodynamic study is important in exploring the severity of the chronic impairment of cauda equina caused by lumbar disk herniation. Detrusor areflexia and loss of bladder sensory indicate more severe degree of impairment of the cauda equine. Q(max) and PVR are helpful in early diagnosis of the chronic impairment of cauda equina.

Paraganglioma of cauda equina

The clinical, radiological and pathological features of a paraganglioma resulting in cauda equina syndrome are described, including magnetic resonance imaging features. The literature is reviewed and discussed.

Papilledema and tumours of the cauda equina: a case report

PURPOSE

Bilateral papilledema is a rare symptom of cauda equina tumours. The authors report a case of neurinoma of cauda equina, which had a bilateral papilledema among its initial symptoms.

CASE REPORT

A 28 years old man showed the presence of a bilateral papilledema; a cerebral MRI did not show any endocranial pathology. After three months the patient started suffering, especially at night, of right-leg-sciatica. A lumbar MRI showed a neurinoma of the cauda equina. The patient was operated and after surgery the papilledema slowly shrank.

CONCLUSIONS

The tumours of cauda equina could cause endocranial hypertension and consequently a papilledema because of hyperproteinorachia. If there is a bilateral papilledema and the cerebral MRI does not show any endocranial pathology, there is the need for the examination of any spinal disorders.

Multiple schwannomas of cauda equina in the absence of von Recklinghausen's disease

Multiple schwannomas in the absence of neurofibromatosis is rarely reported in the literature. We present a 56-year-old female with a history of severe leg and back pain on the left side for one year. Magnetic resonance imaging revealed 4 schwannomas located in the cauda equina in the absence of von Recklinghausen's disease.

Chronic idiopathic myelofibrosis presenting as cauda equina compression due to extramedullary hematopoiesis: a case report

Extramedullary hematopoiesis (EMH) is occasionally reported in idiopathic myelofibrosis and is generally found in the liver, spleen, and lymph nodes several years after diagnosis. Myelofibrosis presenting as spinal cord compression, resulting from EMH tissue is very rare. A 39-yr-old man presented with back pain, subjective weakness and numbness in both legs. Sagittal magnetic resonance imaging showed multiple anterior epidural mass extending from L4 to S1 with compression of cauda equina and nerve root. The patient underwent gross total removal of the mass via L4, 5, and S1 laminectomy. Histological analysis showed islands of myelopoietic cells surrounded by fatty tissue, consistent with EMH, and bone marrow biopsy performed after surgery revealed hypercellular marrow and megakaryocytic hyperplasia and focal fibrosis. The final diagnosis was chronic idiopathic myelofibrosis leading to EMH in the lumbar spinal canal. Since there were no abnormal hematological findings except mild myelofibrosis, additional treatment such as radiothepary was not administered postoperatively for fear of radiotoxicity. On 6 month follow- up examination, the patient remained clinically stable without recurrence. This is the first case of chronic idiopathic myelofibrosis due to EMH tissue in the lumbar spinal canal in Korea.