Transanal irrigation bowel routine for people with Cauda Equina Syndrome

OBJECTIVE

Neurologic bowel incontinence and dysfunction are common with Cauda Equina Syndrome (CES). The study objective was to evaluate the efficacy of Peristeen Anal Irrigation System (PAIS)TM in people with CES.

DESIGN

Clinical Trial.

SETTING

Spinal Cord Rehabilitation outpatient clinic at the Health Sciences Centre in Winnipeg.

METHODS

Twelve participants with a mean age of 46.2 years (range 34-72 years, 4 females) with CES used PAISTM bowel routine for 10 weeks.

OUTCOME MEASURES

Change in Neurogenic Bowel Dysfunction Score (NBD) over 10 weeks relative to baseline. Secondary outcomes: Change in St. Mark's Fecal Incontinence score (SMFI), Cleveland Clinic Constipation score (CCC), and modified Rectal Surgeons Fecal Incontinence Quality of Life Score (QOL) at week 1, 2, 4, 6, 8 and 10 compared to baseline, and self-rating of bowel function at baseline and 10 weeks. Additionally, colonic transit times were assessed using the radioactive markers (Sitzmarks) method.

RESULTS

Ten participants completed the study. Post-intervention primary outcome NBD score improved (p < 0.01). Secondary outcomes also improved significantly, including SMFI (p < 0.01), CCC (p < 0.01), QOL (p < 0.01), self-rating of bowel function (p < 0.01), and transit time improved by 22% (p < 0.05).

CONCLUSION

Overall, a significant improvement was observed with the PAISTM for both primary, as well as secondary outcome measures, without any significant adverse effects. As this non-pharmaceutical method of bowel management is effective and has the potential to improve symptoms of bowel dysfunction in people with CES, it should be considered for those in which traditional methods of managing neurogenic bowel fail.

Aneurysmal subarachnoid hemorrhage complicating spinal subarachnoid hematoma causing acute cauda equina syndrome: a case report

BACKGROUND

Spinal subarachnoid hematoma (SSH) is a known but rare entity that can cause cauda equina compression. The occurrence of SSH associated with aneurysmal subarachnoid hemorrhage has rarely been described in the literature.

CASE PRESENTATION

A 56-year-old woman presented with subarachnoid hemorrhage secondary to a ruptured middle cerebral artery aneurysm and was managed with coiling embolization without stent assistance. There was no history of either lumbar puncture or the use of anticoagulants. The patient developed severe lumbago radiating to bilateral legs nine days after the procedure. Subsequent magnetic resonance imaging demonstrated a SSH extending from L5 to S2 and wrapping around the cauda equina. The patient was treated with intravenous methylprednisolone (250 mg/day) for four consecutive days, followed by a taper of oral prednisolone (20 mg/day) until complete recovery. Magnetic resonance imaging at one month follow-up revealed complete resolution of the SSH.

CONCLUSIONS

Here, we report a case of acute cauda equina syndrome caused by a SSH after aneurysmal subarachnoid hemorrhage, which will facilitate timely intervention of patients with this disorder.

Association of Tarlov cyst with cauda equina syndrome and spinal cord infarction following caudal epidural block: A case report

RATIONALE

Caudal epidural block (CEB), which injects drugs into the epidural space through a sacral hiatus, is considered a safer alternative to other approaches. Serious complications, such as cauda equina syndrome or spinal cord infarction, have been reported very rarely, but their coexistence after CEB, which may be related to the ruptured perineural cyst, also known as a Tarlov cyst, was not reported.

PATIENT CONCERNS

A 40-year-old male patient presented with bilateral lower extremity radicular pain. CEB was performed without image guidance. The patient exhibited sensory deficits below L2, no motor function (0-grade), hypotonic deep tendon reflexes, and no pathological reflexes.

DIAGNOSES

Spinal cord infarction, cauda equina syndrome, and sacral level perineural cyst with hemorrhage.

INTERVENTION

High doses of steroids and rehabilitation were performed.

OUTCOMES

The patient was discharged after 28 days with persistent bilateral leg paralysis and sensory deficits below the L2 level. The patient demonstrated no neurological improvement.

LESSONS

Magnetic resonance imaging, including the sacral area, should be performed before performing CEB, to confirm the presence of a perineural cyst.

Triangular Osteosynthesis as a Treatment of Lumbopelvic Dissociation with Acute Cauda Equina Syndrome in an 11-Year-Old Patient

This case offers a safe and effective method for treating lumbopelvic dissociation in a pediatric patient with cauda equina syndrome using a triangular osteosynthesis construct. After a high-speed accident, an 11-year-old girl was admitted to the hospital with bowel and bladder incontinence and bilateral lower extremity weakness. The orthopaedic trauma and spine teams elected for surgical treatment with a triangular osteosynthesis construct, a procedure usually reserved for adults. The surgery was uncomplicated, and the patient experienced complete resolution of her preoperative symptoms. She is doing well over 1-year postoperatively, with full neurologic recovery, maintained reduction, bony healing, and subsequent implant removal. To our knowledge, this is the youngest reported case of lumbopelvic dissociation treated in this manner and represents a viable treatment option.

Cauda Equina Syndrome Caused by Intradural Bone Graft Materials After Endoscopic Lumbar Fusion

A 53-year-old man presented to the emergency department with severe lower back pain, saddle anesthesia, and urinary dysfunction. He had undergone endoscopic lumbar interbody fusion for highly migrated lumbar disk herniation and lumbar instability 10 days ago. Emergency computed tomography showed that the bone graft materials had migrated to the sacral canal, and a mass with low intensity was seen located at the end of the dural cavity on T2-weighted magnetic resonance imaging. It was suspected that the bone graft materials had migrated into the dural cavity at the operative level and fallen into the end of the dural cavity due to gravity, causing acute cauda equina syndrome (CES). After emergency durotomy, the bone graft materials were completely removed. At the 18-month follow-up, the patient recovered without further complications. This procedure resulted in a rare case of CES caused by intradural bone graft after endoscopic lumbar interbody fusion. Spine surgeons should be aware of this rare but potentially dangerous complication, especially in water-based endoscopic lumbar interbody fusion. This case report shows that early recognition and prompt treatment can significantly improve the symptoms of CES, including saddle numbness and bladder dysfunction. [Orthopedics. 2023;46(6):e384-e386.].

[Transverse myelitis and cauda equina syndrome followed by varicella in a patient with varicella-zoster virus infection]

A 74-year-old man was admitted to our hospital with complaints of weakness in the lower extremities, urinary retention for 10 days, and generalized vesicular rash for 7 days. Spinal magnetic resonance imaging showed contrast enhancement at the Th12-L1 level of the spinal cord and cauda equina. Serum and cerebrospinal fluid varicella-zoster virus (VZV)-immunoglobulin (Ig) G antibody titers were markedly elevated, and VZV-IgM was detected in cerebrospinal fluid. The patient was diagnosed with VZV transverse myelitis and cauda equina syndrome with subsequent varicella and was treated with acyclovir and prednisolone. Two months later, muscle weakness, and dysuria had almost completely resolved. We hypothesize that latent VZV in the ganglia reactivated and caused transverse myelitis, which subsequently spread to the body via the bloodstream, resulting in the development of varicella.

[Long-term results and predictors of postoperative outcomes in patients with cauda equina syndrome following degenerative lumbar spine disease]

Cauda equina syndrome (CES) associated with acute disc extrusion or spinal stenosis often requires emergency surgery. Analysis of the Pubmed, Medline and eLibrary databases revealed a few studies devoted to long-term postoperative outcomes in patients with CES caused by degenerative spine disease.

OBJECTIVE

To evaluate long-term postoperative results and predictors of clinical and neurological outcomes in patients with CES caused by degenerative lumbar spine disease.

MATERIAL AND METHODS. D

Ecompressive and decompressive-stabilizing procedures were performed in 211 patients with CES caused by degenerative lumbar spine disease between 2000 and 2020. Long-term clinical parameters were available in 174 patients with mean follow-up period of 7 years. Sixty-eight patients had unsatisfactory postoperative outcomes. We assessed postoperative clinical and neurological outcomes in patients with CES and predictors of these outcomes.

RESULTS

We identified the following predictors of clinical and neurological outcomes using binary logistic regression model: period between clinical manifestation and surgery >48 hours, preoperative neurological impairment, spinal canal diameter, surgical procedure, dimension of herniated disc, ASA score and long-term postoperative analgesia with narcotic analgesics.

CONCLUSION

Preoperative planning and possible correction of the above-mentioned risk factors will potentially improve postoperative outcomes in patients with CES caused by degenerative lumbar spine disease.

Chronic spontaneous epidural hematoma in the lumbar spine with cauda equina syndrome and severe vertebral scalloping mimicking a spinal tumor: a case report

BACKGROUND

Chronic spinal epidural hematomas (SEHs) are rare clinical entities. SEH with vertebral scalloping is extremely rare, with only a few cases having been reported to date. We report a unique case of spontaneous chronic SEH in the lumbar spine with severe vertebral scalloping mimicking an epidural tumor.

CASE PRESENTATION

A 71-year-old man presented with a 2-month history of lumbar pain and a 3-week history of paresthesia and pain in the right lower extremity, hypesthesia in the perineal and perianal regions, and bladder dysfunction. Computed tomography following myelography revealed an epidural mass lesion on the right side that compressed the dural sac and was associated with severe bony scalloping on the posterior wall of the L4 vertebral body. Magnetic resonance imaging (MRI) on T1- and T2-weighted images revealed a space-occupying lesion with heterogeneous intensity, and T1-gadolinium images showed an intralesional heterogeneous enhancement effect. A tumoral lesion in the spinal canal was suspected, based on preoperative imaging; therefore, a total spinal tumor resection was planned. Intraoperative findings revealed that the brownish lesion adhered to the dura and epidural tissues in the spinal canal, and the space-occupying mass in the scalloped cavity of the posterior wall of the L4 vertebra was encapsulated in red-brownish soft tissues. The lesion was totally resected in a piecemeal fashion, and pathological examination revealed a mixture of tissues that contained a relatively new hematoma with hemoglobin, as well as an obsolete hematoma with hemosiderin and amyloid deposits. The mass was diagnosed as a chronic epidural hematoma with recurrent hemorrhage. The postoperative course was uneventful, and the preoperative neurological symptoms immediately improved.

CONCLUSIONS

The preoperative diagnosis of chronic SEHs is challenging, as MRI results may not be conclusive, particularly in patients with scalloping of bony structures. Thus, chronic SEHs should be considered as a differential diagnosis in cases of suspected tumoral lesions in the spinal canal. To the best of our knowledge, this is the first reported case of acute exacerbation of chronic SEH with cauda equina syndrome and severe vertebral scalloping.

Lumbar decompression surgery for cauda equina syndrome - comparison of complication rates between daytime and overnight operating

PURPOSE

To investigate the incidence of complications from lumbar decompression ± discectomy surgery for cauda equina syndrome (CES), assessing whether time of day is associated with a change in the incidence of complications.

METHODS

Electronic clinical and operative notes for all lumbar decompression operations undertaken at our institution for CES over a 2-year time period were retrospectively reviewed. "Overnight" surgery was defined as any surgery occurring between 18:00 and 08:00 on any day. Clinicopathological characteristics, surgical technique, and peri/post-operative complications were recorded. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals.

RESULTS

A total of 81 lumbar decompression operations were performed in the 2-year period and analysed. A total of 29 (36%) operations occurred overnight. Complete CES (CESR) was seen in 13 cases (16%) in total, 7 of whom underwent surgery during the day. Exactly 27 complications occurred in 24 (30%) patients. The most frequently occurring complication was a dural tear (n = 21, 26%), followed by post-operative haematoma, infection, and residual disc. Complication rates in the CESR cohort (54%) were significantly greater than in the CES incomplete (CESI) cohort (25%) (p = 0.04). On multivariable analysis, overnight surgery was independently associated with a significantly increased complication rate (OR 2.83, CI 1.02-7.89).

CONCLUSIONS

Lumbar decompressions performed overnight for CES were more than twice as likely to suffer a complication, in comparison to those performed within daytime hours. Our study suggests that out-of-hours operating, particularly at night, must be clinically justified and should not be influenced by day-time operating capacity.

Acute bilateral foot drop with or without cauda equina syndrome-a case series

Introduction

Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded.

Methods

Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery.

Results

Seven patients are presented. The mean age at presentation was 52.1 years (range 41–66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other.

Conclusion

When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.

Patient-Reported Bladder, Bowel, and Sexual Function After Cauda Equina Syndrome Secondary to a Herniated Lumbar Intervertebral Disc

BACKGROUND

Cauda equina syndrome (CES) is rare neurosurgical emergency requiring emergent surgical decompression to prevent bladder, bowel, and sexual dysfunction that can have significant impact on quality of life. There is a paucity of data relating to the prevalence of these long-term complications.

OBJECTIVE

The aim of this observational study was to evaluate the long-term prevalence of CES-related bladder, bowel, and sexual dysfunction and impact on quality of life to inform service provision.

METHODS

Participants were selected through coding of operative records of patients who underwent lumbar decompression for CES secondary to a herniated intervertebral disc at two large UK neurosurgical departments between 2011 and 2015 inclusive. A telephone-based survey including both validated and modified tools was used to collect data pertaining to bladder, bowel, and sexual function and impact on quality of life both before development of CES and at the time of the survey, at least 1 year postoperatively.

RESULTS

Of 135 patients contacted, 71 (42 male, 29 female) responded. Post-CES compared to pre-CES, there was higher prevalence and significant intrarespondent deterioration of bowel dysfunction, bladder dysfunction, perception of bladder function, sexual function, effect of back pain on sex life, and activities of daily living/quality of life (p < .0001 for all). Significant differences in individual questions pre-CES versus post-CES were also found.

CONCLUSION

We show high prevalence of long-term bowel, bladder, and sexual dysfunction post-CES, with functional and psychosocial consequences. Our results demonstrate the need for preoperative information and subsequent screening and long-term multidisciplinary support for these complications.

[Spinal infection with spinal cord/cauda equina affection requires emergency handling]

Seventeen cases of infections in spinal structures were reported 2010-2017 to the Swedish Health and Social Care Inspectorate (IVO), a government agency responsible for supervising health care, for missed or delayed diagnosis. All patient records were scrutinized in order to find underlying causes and common factors. The delayed diagnoses were equally found among men and women and most frequent in in the age-group 65 to 79 years of age. The diagnostic delay most probably in many cases led to patient harm and avoidable sequelae, many with severe impairment for daily life. Several of the patients had a locus minoris resistentiae in the spine and in several cases the entry port of infections were cutaneous wounds, for example leg ulcers. The most important finding was that in the majority of cases the clinical investigation was inadequate and the clinical follow-up - while in hospital! - was inferior, without documentation of muscular weakness and sensory loss. In several cases a too passive management was found, when the losses eventually had become apparent, delaying surgical interventions.

Bacterial meningitis and cauda equina syndrome after trans-sacral epiduroscopic laser decompression: A case report

RATIONALE

Trans-sacral epiduroscopic laser decompression (SELD) is a noninvasive pain-relieving procedure for treatment of herniated lumbar disc (HLD), and is known to have positive effects in alleviating lower back pain or radicular leg pain after HLD. However, little is known about the possible complications of SELD.

PATIENT CONCERNS

A 51-year-old woman received SELD with a holmium:yttrium-aluminum-garnet laser for controlling radicular pain due to HLD on L5-S1. However, 5 days after SELD, she complained of headache, and 9 days after the SELD, cauda equine syndrome (CES) symptoms, including motor weakness of both lower extremities (manual muscle testing-left: 3, right: 4), voiding and defecation difficulties, and neuropathic pain, were manifested.

DIAGNOSES

Cerebrospinal fluid (CSF) analysis performed 15 days after the SELD revealed elevated white blood cell count 7560 cells/μL. Staphylococcus hominis sensitive to vancomycin was cultured from CSF. The gadolinium-enhanced magnetic resonance imaging showed diffuse leptomeningeal enhancement along the distal cord and cauda equina. The latency of electrically induced bulbocavernosus reflex (BCR) was delayed in the right side and no response of BCR was presented in the left side. Based on the patient's symptoms and the results of the clinical evaluation, we diagnosed the patient as having a bacterial meningitis and CES.

INTERVENTIONS

The patient received 2 g per day of intravenous vancomycin for 2 months.

OUTCOMES

After treatment with intravenous vancomycin for 2 months, all the CES symptoms were completely resolved.

LESSONS

In this study, we described a patient who had bacterial meningitis after SELD. During SELD, clinicians should keep in mind the possibility of infection.

Understanding cauda equina syndrome: protocol for a UK multicentre prospective observational cohort study

INTRODUCTION

Cauda equina syndrome (CES) is a potentially devastating condition caused by compression of the cauda equina nerve roots. This can result in bowel, bladder and sexual dysfunction plus lower limb weakness, numbness and pain. CES occurs infrequently, but has serious potential morbidity and medicolegal consequences. This study aims to identify and describe the presentation and management of patients with CES in the UK.

METHODS AND ANALYSIS

Understanding Cauda Equina Syndrome (UCES) is a prospective and collaborative multicentre cohort study of adult patients with confirmed CES managed at specialist spinal centres in the UK. Participants will be identified using neurosurgical and orthopaedic trainee networks to screen referrals to spinal centres. Details of presentation, investigations, management and service usage will be recorded. Both patient-reported and clinician-reported outcome measures will be assessed for 1 year after surgery. This will establish the incidence of CES, current investigation and management practices, and adherence to national standards of care. Outcomes will be stratified by clinical presentation and patient management. Accurate and up to date information about the presentation, management and outcome of patients with CES will inform standards of service design and delivery for this important but infrequent condition.

ETHICS AND DISSEMINATION

UCES received a favourable ethical opinion from the South East Scotland Research Ethics Committee 02 (Reference: 18/SS/0047; IRAS ID: 233515). All spinal centres managing patients with CES in the UK will be encouraged to participate in UCES. Study results will be published in medical journals and shared with local participating sites.

TRIAL REGISTRATION NUMBER

ISRCTN16828522; Pre-results.