Marked hypertrophy of the cauda equina in a patient with chronic inflammatory demyelinating polyradiculoneuropathy presenting as lumbar stenosis

Spinal canal decompression for hypertrophic neuropathy of the cauda equina with chronic inflammatory demyelinating polyradiculoneuropathy: A case report

BACKGROUND

Hypertrophic neuropathy of the cauda equina (HNCE) is a rare disease, especially in children. It can be caused by different etiological agents such as inflammation, tumor or hereditary factors. Currently, there is no uniform standard for clinical treatment of HNCE. Furthermore, it is unclear whether spinal canal decompression is beneficial for patients with HNCE.

CASE SUMMARY

We report the case of a 13-year-old boy with enlargement of the cauda equina. The onset of the disease began at the age of 6 years and was initially marked by radiating pain in the buttocks and thighs after leaning over and weakness in the lower limbs when climbing a ladder. The child did not receive any medical treatment. As the disease slowly progressed, the child needed the help of others to walk, and he had a trendelenburg gait. He underwent spinal canal decompression and a nerve biopsy during his hospital stay. A diagnosis of chronic inflammatory demyelinating polyradiculoneuropathy was made based on electrophysiological findings and pathological examination results. Immunoglobulin or hormone therapy was recommended during hospitalization, but his mother refused. After discharge, the boy’s mother helped him carry out postoperative rehabilitation training at home. His lower-limb muscle strength gradually increased, and he could stand upright and take steps. Six mo after surgery, the child was readmitted and began immunoglobulin therapy. Long-term oral steroid treatment was initiated after discharge. The movement and sensation of the lower limbs were further improved, and the boy could walk normally 1 year after surgery.

CONCLUSION

Spinal canal decompression can improve the clinical symptoms of HNCE caused by inflammation, even in children. When combined with specific etiological interventions, spinal cord decompression can lead to optimal outcomes.

Demystifying MR Neurography of the Lumbosacral Plexus: From Protocols to Pathologies

Magnetic resonance neurography is a high-resolution imaging technique that allows evaluating different neurological pathologies in correlation to clinical and the electrophysiological data. The aim of this article is to present a review on the anatomy of the lumbosacral plexus nerves, along with imaging protocols, interpretation pitfalls, and most common pathologies that should be recognized by the radiologist: traumatic, iatrogenic, entrapment, tumoral, infectious, and inflammatory conditions. An extensive series of clinical and imaging cases is presented to illustrate key-points throughout the article.

Inflammatory hypertrophic cauda equina following intrathecal neural stem cell injection

INTRODUCTION

Potential benefit from stem cell treatments has more patients seeking treatment without understanding possible risks.

METHODS

We describe a woman who presented with progressive bilateral leg pain, numbness, and gait difficulties. A prior stroke, macular degeneration, osteoarthritis, and depression, led her to receive intrathecal neural stem cell therapy overseas 1 year before onset of symptoms.

RESULTS

Imaging showed marked enlargement of lumbosacral roots of the cauda equina, which was not seen before stem cell treatment. Electrodiagnostic studies confirmed chronic multiple lumbosacral radiculopathies. Biopsy of a lumbar dorsal sensory root showed myelinated fiber degeneration and loss, with endoneurial inflammation. The hypertrophic inflammatory cauda equina syndrome was potentially triggered by the prior intrathecal neural stem cell injection.

CONCLUSIONS

Safety of intrathecal stem cell treatments is not routinely regulated in overseas stem cell facilities. We wish to bring this potential complication to the attention of health care providers.

Clinical and imaging findings in three patients with advanced inflammatory demyelinating polyradiculoneuropathy associated with nerve root hypertrophy

OBJECTIVES

Chronic inflammatory demyelinating polyradiculoneuropathy is a treatable neuropathy that is challenging to diagnose and has a broad spectrum of presentations. We report the clinical, electrodiagnostic, and radiographic presentations in three patients whose workup revealed hypertrophic nerve roots.

METHODS

We retrospectively reviewed the clinical, electrodiagnostic, and imaging data for patients diagnosed with chronic inflammatory demyelinating polyradiculoneuropathy over a 3-year period.

RESULTS

All patients had features of proximal and distal neuropathy with progressive or recurrent courses. Diagnosis and management were significantly altered by the concomitant clinical findings and/or radiographic findings.

CONCLUSIONS

Our cases highlight the use of magnetic resonance imaging to evaluate for nerve root hypertrophy as an additional tool to electrodiagnostic testing in the setting of refractory or atypical neuropathy condition. Awareness of the radiographic features will assist in confirmation of the diagnosis, institution of the appropriate therapy, and prevention of inadequate or delay of treatment.

Selective cauda equina hypertrophy with idiopathic inflammation

A 20-year-old woman with selective cauda equina hypertrophy presented with muscle weakness and severe pain in the lower extremities. Serial immunotherapy was not effective. We performed biopsy of the cauda equina, and laminectomy and duraplasty of the thoracolumbar region. Biopsy revealed marked infiltration of small lymphocytes and foamy macrophages in the endoneurium. Three years after decompression surgery, her symptoms have improved slightly without progression or relapse. This is the first case of selective cauda equina hypertrophy with idiopathic inflammation. We propose that this is a new disease entity.

Malignant lymphoma originating in the cauda equina mimicking the inflammatory polyradiculoneuropathy

A 67-year-old woman was diagnosed with inflammatory polyradiculoneuropathy. The intravenously administered immunoglobulin (IVIG) treatment that she received several times over a 3-year period relieved her clinical symptoms of muscle weakness and sensory disturbances, but these symptoms had worsened thereafter despite further IVIG treatment. MRI detected a solid tumor involving the cauda equina and pathological examinations confirmed this to be malignant lymphoma. The clinical and radiological findings for the malignant lymphoma of the cauda equina in this patient were quite similar to those for the inflammatory polyradiculoneuropathy.

Multifocal acquired demyelinating sensory and motor neuropathy presenting as a peripheral nerve tumor

A man with multifocal acquired demyelinating sensory and motor neuropathy (MADSAM), or Lewis-Sumner syndrome, presented with a progressive left lumbosacral plexus lesion resembling a neurofibroma. After 7 years he developed a left ulnar nerve lesion with conduction block in its upper segment. Treatment with intravenous immunoglobulin improved the symptoms and signs of both lesions. We conclude that inflammatory neuropathy must be considered in the differential diagnosis of peripheral nerve tumors, and that unifocal lesions may precede multifocal involvement in MADSAM by several years. In addition, we discuss the clinical features in 9 patients attending a specialist peripheral nerve clinic and review the literature.