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AbstractBackgroundMethodResultsConclusionThe guidance for clinicians on who requires further investigation when suspecting cauda equina syndrome has become clearer in England following the publication of the national recommendations. This does not have specific advice for those patients who have had recent imaging with no compression, returning to a healthcare provider with a change in symptoms. These cases can cause difficulty for clinicians with limited access to imaging who can often be reassured by previous imaging.This study presents a retrospective review of the case notes of 45 patients presenting on two occasions to the same Emergency Department who underwent magnetic resonance imaging due to the clinical diagnosis of cauda equina syndrome. Those with compression of the cauda equina on the second visit were compared to those without a compressive cause for their symptoms.Patients presenting with an increased number of clinical symptoms associated with cauda equina syndrome on their return visit were more likely to have compression of the cauda equina on imaging.The small numbers in this study would suggest caution, however, if patients present with an increasing number of symptoms further imaging should be considered, even with previous reassuring scans. [ABSTRACT FROM AUTHOR]

Cauda equina syndrome (CES) can present with a varied constellation of clinical signs and symptoms, which together with the time-sensitive nature of the condition and risk of catastrophic clinical outcome, presents a significant challenge to those assessing patients with this suspected diagnosis. Anal tone is commonly tested during initial assessment using a digital rectal examination (DRE). This study aims to evaluate the diagnostic value of anal tone and perianal sensation assessment in patients with suspected CES and report modern prevalence data on CES within a neurosciences centre. Consecutive patients with suspected CES presenting over three years to the Emergency Department (ED) of a busy tertiary centre were included in the study. History and examination findings, documented in the ED notes, were assessed and these variables were correlated with the presence or absence of cauda equina compression on subsequent magnetic resonance imaging (MRI). Out of 1005 patients with suspected CES, 117 (11.6%) had MRI confirmed cauda equina compression (MRI + ve CES). 35% of MRI + ve patients and 31% of MRI -ve patients had reduced anal tone. Using univariate and multivariable logistic regression analyses, no associations were found between abnormal anal tone and MRI + ve CES for patients of all ages. The univariate logistic regression analysis identified altered perianal sensation to be significantly associated with MRI + ve CES in patients ≤42 years old. This association was no longer present when an adjusted multivariable logistic regression was performed. The prevalence of MRI + ve CES was 11.6%. Our findings suggest that the clinical finding of reduced anal tone has no demonstrable diagnostic value for those with suspected CES, either in itself or in combination with other clinical findings. Further studies are needed to confirm the diagnostic efficacy of assessing perianal sensation in this context. [ABSTRACT FROM AUTHOR]

Spinal epidural lipomatosis [SEL] is defined as an excessive accumulation of extradural normal adipose tissue. This condition may be idiopathic or acquired. Surgical decompression is considered the gold standard treatment in patients presenting with progressive neurologic deficit. We report a case of a 69-year-old male patient presented with neurogenic claudication and lower left limb radiculopathy. The magnetic resonance imaging (MRI) revealed a L5-S1 epidural compression sustained by a large epidural plaque whose signal was consistent with adipose tissue. A conservative approach, including weight loss attempt, revealed unsuccessful and the patient presented some months after the diagnosis at the emergency department with acute onset bilateral drop foot, more severe on the right side and urinary disturbances. Microsurgical decompression via L5 laminectomy and partial L4 laminectomy and fatty plaque debulking was performed. The post operative course was uneventful and at the two months post operative follow up the patient reported a significative improvement of the pre operative neurological signs and symptoms and of pain control. SEL deserves attention as an identifiable cause of radiculopathies, typically attributed to spinal stenosis, with a higher incidence than previously reported. Moreover cases of acute onset of cauda equina like syndrome were reported in patent affected by SEL, probably related to a local venous engorgement with stasis and edema. Therefore it should be considered as a possible diagnosis not only in patients complaining of stenosis-type symptoms but also in cases of acute neurological decline with cauda equina like syndrome, especially when provided with a "benign" imaging reading. [ABSTRACT FROM AUTHOR]

Pediatric intraspinal epidermoid cysts are rare with potential to cause life-altering outcomes if not addressed. Reports to date describe symptomatic presentations including loss of bladder or bowel function and motor and sensory losses. This case report identifies the diagnostic challenge of an asymptomatic intraspinal epidermoid cyst in the cauda equina region presenting in a 7-year-old male with juvenile idiopathic arthritis (JIA). An advanced physiotherapist practitioner assessed and diagnosed a previously healthy 7-year-old-male of South Asian descent with JIA based on persistent knee joint effusions. Complicating factors delayed the investigation of abnormal functional movement patterns, spinal and hip rigidity and severe restriction of straight leg raise, all atypical for JIA. Further delaying the diagnosis was the lack of subjective complaints including no pain, no reported functional deficits, and no neurologic symptoms. A spinal MRI investigation 10-months from initial appointment identified intraspinal epidermoid cysts occupying the cauda equina region requiring urgent referral to neurosurgery. Clinical characteristics and pattern recognition are essential for diagnosing spinal conditions in pediatric populations. Diagnostic challenges present in this case included co-morbidity (JIA), a severe adverse reaction to treatment, a lack of subjective complaints and a very low prevalence of intraspinal epidermoid cysts. Early signs of pediatric asymptomatic intraspinal epidermoid cysts included abnormal functional movement patterns, rigidity of spine, severely limited straight leg raise and hip flexion without pain. Advanced physiotherapist practitioners can be integral to pediatric rheumatology teams considering their basic knowledge in musculoskeletal examination and functional mobility assessment when identifying rare spinal conditions that present within the complex context of rheumatic diseases. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodsResultsConclusion\nIMPLICATIONS FOR REHABILITATIONTo explore women’s lived experiences of intimacy, sexuality and sexual functioning in the context of cauda equina syndrome (CES).Ten women completed an in-depth semi-structured interview exploring the psychosocial impact of CES on their sexuality and data were analyzed using Interpretative Phenomenological Analysis (IPA).One superordinate theme was generated: “Sexuality forever altered, it’s changed completely,” reflecting the enduring impact of CES on women’s sexuality. Five subordinate themes emerged reflecting a range of changed roles and relationships, primarily associated with loss of sexual identity and a sense that health professionals did not prioritize sexual functioning (1): Loss of worth as a sexual being: “Feel like a nothing” (2) Relationships have changed: “It’s not a meeting of equals anymore” (3) Lack of professional support: “We don’t like to talk about anything below the waist” (4) Challenges for motherhood: “What kind of future will they have with a mother like me…” and (5) Finding ways of coping: “Closed the door on it.”Findings highlight the detrimental effect of CES, directly and indirectly, on women’s sexuality. There is a need for a multidisciplinary approach to address the physical, emotional, cognitive, and behavioural effects experienced in relation to sexuality as part of a rehabilitative process.The lived experience of sexuality and sexual function is negatively affected in women with cauda equina syndrome (CES).Some women make positive adjustments in terms of alternative forms of intimate expression while others “close off” their sexuality as a coping response.Women perceive that sexuality and sexual function is not adequately addressed by health professionals.Rehabilitation should include a multidisciplinary focus on sexuality after CES.The lived experience of sexuality and sexual function is negatively affected in women with cauda equina syndrome (CES).Some women make positive adjustments in terms of alternative forms of intimate expression while others “close off” their sexuality as a coping response.Women perceive that sexuality and sexual function is not adequately addressed by health professionals.Rehabilitation should include a multidisciplinary focus on sexuality after CES. [ABSTRACT FROM AUTHOR]

Some patients with lumbar spine stenosis (LSS) have severe low back pain (LBP) with only mild leg symptoms. The effects of decompression surgery for such patients remain unknown. Of 818 patients with LSS who underwent surgical treatment in our institution from 2011 to 2019, eight patients had a numeric rating scale (NRS) score of ≥7 for LBP and 3≤ for leg pain. The patients' age, sex, clinical characteristics, preoperative leg symptoms, and level of LSS were investigated. The detailed characteristics of LBP, such as the disease duration, location of LBP, and exacerbating factors, were obtained from each patient. The NRS and Japanese Orthopaedic Association (JOA) scores for LBP were evaluated on admission, at 1 and 3 months postoperatively, and at the final follow-up (>1 year postoperatively). All patients were male with a mean age of 71.5 years (range, 57–82 years). LBP was exacerbated during walking in six patients and during an extension posture in three patients. The median duration of LBP was 2.9 years (range, 0.3–7 years). The stenosis was located at L2/3 in three patients, L3/4 in five patients, and L4/5 in seven patients. The stenosis involved one level in three patients and more than two levels in five patients. Other pathologies, such as sacroiliac joint lesions, facet pain, superior/middle cluneal nerve pain, and discogenic pain, were excluded by diagnostic anesthetic block and detailed physical examination. All patients underwent posterior decompression surgery without fusion. In all eight patients, the NRS score for LBP significantly improved from 7.6 (range, 7–10) to 1.7 (range, 0–3) and the JOA score improved from 13.1 (range, 4–19) to 21.8 (range, 18–27). A low proportion of patients showed walking-evoked severe LBP with mild leg symptoms due to lumbar spine stenosis. The patients' pain was improved by decompression surgery with satisfactory results. [ABSTRACT FROM AUTHOR]

Hemangioblastoma is a rare benign vascular tumour of the central nervous system that occurs either sporadically or in association with Von Hippel-Lindau syndrome. Hemangioblastoma can be found throughout the central nervous system and usually present with late manifestations due to their slow growth rate. Cauda equina hemangioblastomas are extremely rare, and in the literature, no cases are reported on the surgical management of pregnant patients with this condition. We report the case of a young woman with back pain and sphincter dysfunctions in whom an L1-L2 hemangioblastoma was diagnosed. We describe the perioperative and surgical strategies we adopted to successfully treat the patient and preserve the fetus well-being. [ABSTRACT FROM AUTHOR]

Background: Cauda equina syndrome (CES) is a challenging condition and it can be caused by variable entities. Leptomeningeal carcinomatosis (LC) is a multifocal seeding of the leptomeninges by malignant cells and it is observed in 1-8% of patients with solid tumors. Diagnosis of intradural metastases of the cauda equina is often delayed due to the non-specific characteristics of this condition but also to the delay of presentation of many patients. Cauda equina metastases usually occur in advanced cancers, but rarely can be the first presentation of disease. Case description: A 63-year-old man presented with 6 months history of low back pain and 20 d history of bilateral sciatica, hypoesthesia of the legs and the saddle, flaccid paraparesis and bowel incontinence determine by multiple nodular small lesions on the entire cauda equina with contrast-enhancement. Total-body CT showed a millimetric lesion at the lung. The patient underwent L2-L5 laminectomy and subtotal removal and histological examination showed a small cell lung carcinoma metastasis. Conclusions: In the literature, 54 cases of CES from non-CNS tumor metastasis are described. The diagnosis is challenging, back pain, with or without irradiation to the lower limbs, is the most frequently reported disturbance. In about 30% of patients there is no known malignancy and CES is the first clinical presentation. Treatment of choice is surgery, followed by radiotherapy and less frequently adjuvant chemotherapy. The surgical removal is almost always incomplete and functional outcome is often not satisfactory. Prognosis is poor. [ABSTRACT FROM AUTHOR]

Primary paragangliomas (PGs) are extra-adrenal neuroendocrine tumours that are extremely rare. Multiple lesions in the central nervous system raise suspicion of a metastatic process. Lack of consensus on their management warrants the categorization of existing literature to evaluate management options. A systematic review of the medical literature on paraganglioma within the cranial vault was completed in accordance with PRISMA guidelines using the Medline database. Tumour physical measures, management parameters, and immunohistochemistry of all documented cases of primary and secondary paraganglioma within the cranial vault were descriptively compared. This review was augmented by comparison with our centre's case of a 48-year-old man diagnosed with metastatic PG originating in the cauda equina and seeding in the cerebellum. Histological parameters within the literature was also established. The systematic literature review yielded published 52 papers. Most prevalent primary intracranial PGs (n = 37) were in the sellar region (78%, n = 23) and the cerebellum (21%, n = 6). The highest progression free survival was seen in primary sellar PGs (87.5% by 34.5 months) and cerebellar PGs (100% by 35.7 months) when treated with adjuvant radiotherapy with subtotal resection or gross total resection, respectively. Contrasting, the most frequent intracranial PGs metastases (n = 15) occurred in the cerebellum (36%, n = 6), and the cerebral parenchyma (29%, n = 4). Their recurrence rate was between 4 and 10% and these metastasized PG in the cerebellum are slow growing (8.9 years, range: 3–22 years). Adjuvant radiotherapy with Gross Total Resection resulted in the optimum progression-free survival (100% up to 48 months) for the patient with PGs metastasis to the cerebellum. Metastatic PGs tend to be slow-growing and are clinically silent tumours. Diagnosed patients should undergo regular surveillance neuroradiological assessment, regardless of symptomatology, for metastases along the complete neural axis. We recommend operative management with GTR and adjunct RT in these patients. [ABSTRACT FROM AUTHOR]

This study evaluated the impact of the Salisbury Protocol for Assessment of Cauda Equina Syndrome (SPACES) on the waiting time for MRI in patients presenting with suspected Cauda Equina Syndrome (sCES) within a UK district general hospital. All consecutive patients undergoing an MRI scan in our hospital, for sCES, over a 12 month period, prior to and following the introduction of SPACES, were identified. Patient's gender, age, MRI diagnosis, time from MRI request to imaging and outcome were recorded. In the year prior to the introduction of SPACES, 66 patients underwent MRI for sCES, out of which 10.6% had cauda equina compression (CEC), 63.5% had other spinal pathology and 25% had a normal scan. In the year after introduction of SPACES, 160 patients underwent MRI for sCES out of which 6.2% had CEC, 70.7% had other spinal pathology and 23% had a normal scan. Despite the referrals for sCES increasing by more than 2-fold following the introduction of SPACES, the median time from MRI request to scan decreased from 9.1 to 4.2 hours (p = 0.106, Mann-Whitney-U) and the number of patients transferred to the regional hub hospital decreased from 7 to 3. Implementation of SPACES for patients with sCES resulted in a substantial reduction in waiting time for MRI and decreased the number of transfers to the regional hub hospital. Based on our early experience, we encourage other centres within the UK to introduce such a pathway locally, to improve the management of patients with sCES. [ABSTRACT FROM AUTHOR]

The coexistence of vascular malformations in the conus medullaris and cauda equina has been rarely reported, and the complex angioarchitecture in multiple arteriovenous lesions remains poorly understood. A 17-year-old woman presented with a sudden-onset, stepwise worsening of weakness and pain in the bilateral legs. Angiography revealed conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas. One of the drainers was shared between the coexisting lesions and harboured a varix. Targeted embolisation of a fistulous point in the conus lesion was performed with precaution to prevent occluding the common drainage route, which led to symptom improvement with angiographical diminishment of the varix. Recognising that communications between drainers can be observed in multiple spinal arteriovenous lesions is important in facilitating a safe embolisation. Cautious assessment of angiogram with fusion images of cone-beam computed tomography and volumetric T2 magnetic resonance imaging can help in establishing the diagnosis and treatment strategy. [ABSTRACT FROM AUTHOR]

The coexistence of vascular malformations in the conus medullaris and cauda equina has been rarely reported, and the complex angioarchitecture in multiple arteriovenous lesions remains poorly understood. A 17-year-old woman presented with a sudden-onset, stepwise worsening of weakness and pain in the bilateral legs. Angiography revealed conus medullaris arteriovenous malformation and cauda equina arteriovenous fistulas. One of the drainers was shared between the coexisting lesions and harboured a varix. Targeted embolisation of a fistulous point in the conus lesion was performed with precaution to prevent occluding the common drainage route, which led to symptom improvement with angiographical diminishment of the varix. Recognising that communications between drainers can be observed in multiple spinal arteriovenous lesions is important in facilitating a safe embolisation. Cautious assessment of angiogram with fusion images of cone-beam computed tomography and volumetric T2 magnetic resonance imaging can help in establishing the diagnosis and treatment strategy. [ABSTRACT FROM AUTHOR]

The aim of this study was to describe a very rare presentation of ependymoma that can derive from intraoperative complications for surgeons and increased morbidity for the patients. Multiple cases of mobile cauda equina tumors leading to inadequate approach have been reported in the literature, however, the reports of ependymoma histology are very rare. This report describes the third adult case in recent years and a retrospective review of cases reported in the literature until today. We show the clinical and radiographic presentation of a 79 years old patient that presented a mobile cauda equina tumor in the preoperative image, who went to surgery for resection and arthrodesis, obtaining in post-operative histology the diagnostic of ependymoma. The preoperative image shows the migration of the tumor avoiding the wrong approach. The patient went to surgery for laminectomy, pedicular screw arthrodesis L1-S1, and tumor removal, obtaining a complete resection and confirmed histology diagnostic of ependymoma, unfortunately, the patient died five days after by a cardiac arrest. The recent literature reports only four cases of mobile ependymoma, two of them in pediatrics patients and just only two adult cases, which means this is the third adult case of an ependymoma. Mobile cauda equina ependymoma is a very rare neoplasm presentation but is an entity that can lead to mistakes in the approach and may be useful for the neurosurgeons who day per day treat this pathology beware of this possibility. [ABSTRACT FROM AUTHOR]

Lumbar spinal stenosis (LSS) is a common and important spinal surgical problem. Currently there is no universally accepted quantitative approach to the radiological measurement of LSS. LSS can be described qualitatively with reference to facet and ligamentous hypertrophy, lack of perineural or intraforaminal fat, and reduced CSF around the cauda equina. Quantitative descriptions do exist e.g., lumbar canal antero-posterior diameter, but these are unidimensional and do not consider normal variation in anatomy. We propose a universal and individualised measurement system for the quantitative radiological assessment of lumbar spinal stenosis. A retrospective case series of patients who had undergone surgery for symptomatic lumbar spinal stenosis over a 3 year period. Pre-operative lumbar spine MRI were analysed. Each patient had the degree of lumbar canal stenosis quantified using our novel approach. Our novel formula for the quantitative radiological assessment of lumbar spinal stenosis is two dimensional, repeatable and presented as a percentage, to correct for the individual patient. The surface area of the lumbar spinal canal at the level of stenosis is measured in mm2 plus the adjacent 2 levels which are then averaged. The calculation then becomes (A-S/A) x 100 = R, where S is the canal surface area at the stenosed level in mm2, A is the average canal surface area of the two levels adjacent to the level of interest and R is the relative degree of lumbar spinal canal stenosis expressed as a percentage. Measurements are calculated using axial T2 weighted images. This novel quantitative measurement formula for the radiological assessment of lumbar canal spinal stenosis is quick and simple to calculate and most importantly adjusts for the individual patient's normal or degenerative anatomy. This new measurement tool will need validation against specific clinical and operative criteria in the future. [ABSTRACT FROM AUTHOR]

Foot drop due to lumbar disc herniation (LDH) is a relatively common finding in spinal practice. Bilateral foot drop (BFD) due to LDH is an extremely rare condition with only a few reported cases. We describe the case of a middle-aged man presenting with a rapid onset BFD with back and leg pain. Urgent MRI revealed an L4-L5 centrally located LDH with bilateral compression of the L5 nerve roots and the cauda equina centrally. About 4 h after presentation surgery was performed adopting a bilateral L4-L5 interlaminar approach and the prolapsed disc was removed. Nine months after surgery, the patient showed a complete recovery of his deficit. We discuss the advantages of this approach in this urgent situation and we compare it with other techniques. [ABSTRACT FROM AUTHOR]

We report a case of cauda equina syndrome related to the use of fibrin glue dural sealant "TISSEEL". Incidental durotomy (ID) is not uncommon in revision spinal surgery. Augmentation of the dural repair after primary closure is gaining popularity. The use of dural sealants is not risk-free. A 65-year old man who underwent revision lumbar decompression surgery developed postoperative cauda equina syndrome. He had urinary retention, bilateral leg pain and perianal numbness on the third postoperative day. We believe this complication was related to the use of fibrin glue to manage an ID. After the urgent surgical removal of the fibrin glue patch, the patient fully recovered with no residual neurological deficit. Cauda equina syndrome development is a potential complication after the use of fibrin glue to augment intraoperative ID. Surgeons should be aware of this potential risk so it can be managed in a timely fashion. [ABSTRACT FROM AUTHOR]

Lymphomatosis cerebri (LC) and cauda equina lymphoma are both rare forms of primary central nervous system lymphoma (PCNSL). LC is characterized by diffuse bilateral non-enhancing (or partially enhancing) inltrative lesions without mass effect, which can be easily confused with other forms of leukoencephalopathy and, thus, lead to delays in diagnosis. For the first time, a case of LC concomitant with cauda equina involvement confirmed by brain stereotactic biopsy is presented. This case highlights the necessity of using a multimodal strategy in diagnosing PCNSL, including multimodal magnetic resonance, cerebral spinal fluid cytology, flow cytometry and fluorodeoxyglucose positron emission tomography/computed tomography. [ABSTRACT FROM AUTHOR]

Emergencies account for 60% of UK neurosurgical workload. We analysed the emergency referrals made to the on-call neurosurgical registrar in a regional centre over three years, aiming to identify temporal trends in volume of referrals, admission practices and major diagnostic categories contributing to referrals and admissions. Individual referrals recorded in on-call databases were processed to extract basic demographics, call timing, diagnosis category and whether the patient was admitted under neurosurgery. Linear regression analysis was used to identify temporal trends across the three years. A total of 18128 calls were made to the on-call registrar between 2016 and 2018, with a significant increase in monthly calls. On average, one call was received every 88 minutes. An increasing proportion of these calls were taken out of office hours. Diagnostic categories accounting for the largest percentage of calls were traumatic brain injury (17.7%) and cauda equina syndrome (13%). Significant increases in referral volume were seen in cauda equina syndrome, traumatic brain injury, spinal trauma and spinal tumours, while no category had a significant decrease. The admission rate was 17.1% – no change was seen in this across the study period, resulting in increasing numbers of admissions, reflecting increasing referrals. Categories most likely to result in admission were hydrocephalus (41.1%), spontaneous subarachnoid haemorrhage (39.4%), intracranial infection (32.6%) and chronic subdural haematoma (CSDH, 32.2%). A change in admission rate was seen only for CSDH, with a significant increase in the percentage of referrals across the study period. Emergency neurosurgical referrals continue to rise in the UK at a rate exceeding population growth. This implies a decreasing referral threshold. However, the constant admission rate suggests either an increasing amount of neurosurgical pathology, the threshold for admission/intervention has decreased, or a combination. Neurosurgical services need to adapt in order to meet increasing demands. [ABSTRACT FROM AUTHOR]

A previously well 34-year-old man presented with severe pseudotumour cerebri. Imaging showed that he had a cauda equina tumour which proved to be a medulloblastoma. There was no tumour mass in the posterior fossa so we assume that this was a primary leptomeningeal medulloblastoma. In patients with somewhat atypical pseudotumour, spinal imaging should always be considered. [ABSTRACT FROM AUTHOR]

Southern Africa contains a diverse and endemic scorpion fauna, but with biological aspects remaining largely unexplored for this group. In order to gain biological insights into an understudied scorpion species, the current study investigates fine-scale spatial distributions and sexual dimorphism in the South African endemic Drab Thick-tail Scorpion (Parabuthus planicauda). The species closely track rocky areas, with the sexes homogenously distributed across habitats. Varying adult sex ratios are evident at each sampling area, likely influenced by differing vegetation cover and predation pressures. When considering size-corrected measurements, several characters are significantly sexually dimorphic in P. planicauda; this sexual dimorphism is not readily observable (<10% difference in size) based on uncorrected measurements, thereby rendering the identification of males and females in the field difficult. Even so, sexually dimorphic characters in females appear to be shaped mainly by natural selection (e.g. carapace width, pedipalp patella and metasoma), likely for enhanced feeding ability, fecundity, parental care and juvenile survival. In contrast, the male morphology may be primarily subject to sexual selection pressures on features used during courtship and mating (e.g. pectines, chela movable finger, pedipalp femur, 2nd and 4th legs). Taken together, the results reported on here add novel preliminary information on the understudied biological aspects of a South African endemic scorpion species. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to validate the cauda scale (TCS) in an external population. TCS was proposed as a tool to be used to predict the likelihood of cauda equina compression. Methods: We analysed the presenting condition of consecutive patients attending the emergency department undergoing a magnetic resonance scan with a clinical suspicion of cauda equina syndrome (CES). The findings were graded according to TCS for those with and without radiological compression of the cauda equina. Logistic regression was applied to the data in accordance with the original paper. Results: Patients were included over a 14 month period (n = 313), subsequent imaging revealed CES compression in 34 cases and no CES compression in 279. The TCS proposed that small values meant a more likely diagnosis of CES, the data showed the opposite of this with the highest number of patients with CES scoring a maximal 9 on TCS (mildest symptoms). Conclusions: Our data suggests that TCS has potential limitations in identifying patients with CES and needs further work prior to implementation. [ABSTRACT FROM AUTHOR]

Objectives: Cranial neuropathies (CNs) can be due to a wide spectrum of causes, and the differential diagnosis is particularly challenging in patients with positive history of hematological malignancies, when neoplastic meningitis (NM) must be excluded. Patients and Methods: We retrospectively selected a series of twelve haematological patients with isolated cranial neuropathies (ICNs) or multiple cranial neuropathies (MCNs). among 71 patients that developed neurologic symptoms during different stages of the cancer, between 1 January, 2010 and 31 December, 2017. Brain and cauda equina magnetic resonance imaging (MRI) with gadolinium, cerebrospinal fluid (CSF) analysis, including flow cytometry for cell immunophenotyping and microbiological exams were performed in all patients. Results: Patients developed signs and symptoms of involvement of isolated (n = 11) or multiple (n = 1) cranial nerves, at different stages of the primary disease, and, in 5 of these cases in complete remission after hematopoietic stem cell transplantation. Among the 5 cases that eventually were diagnosed as having NM, cerebrospinal fluid was positive for neoplastic cells in 3, and MRI gadolinium-enhancement was present in 3. The other episodes were attributed to heterogeneous pathologies that were unrelated to meningeal infiltration by neoplastic cells. Conclusions: Our observations confirm that NM in haematological malignancies can yield insidious isolated signs of cranial nerves. Only a multidisciplinary approach allows prompt recognition of these conditions through a challenging process of differential diagnosis, and proper therapies. [ABSTRACT FROM AUTHOR]

Although spinal meningiomas are uncommon in children, clear cell meningioma has been described as the most common variant of spinal meningiomas in the pediatric age group. 24 cases of pediatric spinal clear call meningioma have been reported in the literature. We report one case and review the literature regarding pediatric spinal clear cell meningioma. [ABSTRACT FROM AUTHOR]

Facet joint cysts are a feature of lumbar spondylosis and are an uncommon cause of radiculopathy. Facet joint cyst haematoma is a very rare entity and has previously been reported as a subacute cause of leg pain, back pain, sensory deficit and lower limb weakness. We present the unique case of facet joint cyst haematoma presenting as cauda equina syndrome. An 81 year old lady presented with a 7 day history of back pain and left foot drop, a 1 day history of perineal numbness and urinary retention with absent rectal tone, perianal anaesthesia and left leg hypoaesthesia. Emergency MRI scan demonstrated spinal canal stenosis as the aetiology of her cauda equina syndrome. She was taken to theatre for emergency lumbar decompression. At operation a facet joint haematoma compressing the cauda equina was found and extirpated with complete resolution of symptoms. In this case, the aetiology of cauda equina compression was not demonstrated effectively on pre-operative MRI scanning. [ABSTRACT FROM AUTHOR]

Myxopapillary ependymoma (MPE) is a rare variant of ependymoma that is most commonly located in the cauda equina and filum terminale. We present a case of 23-year-old man diagnosed with MPE in the fourth ventricle and sacral canal area with extensive disseminated lesions along the cerebrospinal ventricular system. Additionally, a molecular pathological diagnosis was performed. The patient underwent a craniotomy and a lumbar laminectomy. In the course of 18 months of follow-up, the patient have recovered very well. [ABSTRACT FROM AUTHOR]

Bowel and bladder function are at risk during tumor resection of the conus, cauda equina, and nerve roots. This study demonstrates the ability to acquire transcranial electrical motor evoked potentials (TCeMEPs) from the urethral sphincter muscles (USMEPs) by utilizing a urethral catheter with an embedded electrode. A retrospective analysis of intraoperative neurophysiological monitoring (IONM) data from nine intradural tumors, four tethered cord releases, and two spinal stenosis procedures was performed (n = 15). The cohort included seven females and eight males (median age: 38.91 years). A catheter with embedded urethral electrodes was used for recording TCeMEPs and spontaneous electromyograph (s-EMG) from the external urethral sphincter (EUS). USMEPs were obtained in 14 patients (93%). The reliability of TCeMEP from the external anal sphincter (EAS) was variable across all patients. In patient 7, the TCeMEP recordings from the urethral sphincter were not present before incision; however, following the resection of the tumor, the USMEP recordings were obtained and remained stable for the remainder of the procedure. Patient 7 had subsequent improvement in bladder function postoperatively. Patient 4 exhibited a 50% increase in the amplitude of the USMEP following tumor resection and exhibited improved bladder function as well postoperatively. In this small series, we were able to acquire consistent and reliable MEPs when recorded from the urethral sphincters. More study is needed to establish a better understanding of the value added by this modality. USMEPs can be attempted in surgeries that put the function of the pelvic floor at risk. [ABSTRACT FROM AUTHOR]

Intraspinal epidural lymphangioma of cauda equina are extremely rare, only three cases have been reported in the past. We report a 63-year-old female with lymphangioma at S1–S2 level which was resected under epidural anesthesia using a percutaneous full endoscope with no evidence of recurrence at 19 months follow-up. [ABSTRACT FROM AUTHOR]

Introduction: Cauda equina syndrome (CES) is a condition with significant implications and medico-legal profile. The literature still lacks large primary studies to provide strong evidence for a robust management pathway. Statements from Neurosurgical and Spinal societies support early diagnosis and imaging but this has not resulted in any noticeable shift in referral pattern. We strongly feel the need for a nationally agreed, evidence-based referral pathway in practice. We present our large series and in-depth analysis of the referral pathway to provide strong evidence for more robust referrals and management. Methods: We reviewed 250 referrals of suspected CES (sCES) to the regional neurosurgical unit, evaluating the importance of clinical findings and the imaging pathway. Results: After clinico-radiological evaluation only 32 (13%) had confirmed CES requiring urgent surgery. There was no significant difference in terms of clinical presentation between these true cases of CES (tCES) and false cases (fCES). Imaging was therefore the key rate-limiting step. MRI was the most common investigation used. 73 patients presented without imaging out of hours (OOH). In this group, investigation was delayed to the next day in 60/73 (82%) patients while only 13 (18%) patients underwent OOH MRI. Only 2 (3%) were able to have this at their local hospital. Conclusions: As with previous studies we conclude that signs/symptoms are insufficient to identify tCES. Taking into consideration the improved outcome with early diagnosis, the importance of early scanning in diagnosing tCES, and the poor availability of OOH MRI scanning outside of neurosurgical units, we recommend a national policy of 24/7 MRI availability for cases of sCES at all hospitals with MRI scanners. This would remove the 87% of patients not requiring urgent surgery from an unnecessary and distracting referral process. [ABSTRACT FROM AUTHOR]

Aim:To quantify the clinical findings in patients with potential cauda equina syndrome (CES). Methods: Three domains were selected: bladder function (B), perianal sensation (S) and anal tone/squeeze (T). A quantified score was given to symptoms and signs in each domain. Results: The lowest score in each domain and the lowest sum score (the most severe lesion) is 0. The best sum score is 9 (the normal patient). Conclusion: TCS can improve the clinical assessment and management of patients with possible CES and improve communication between the doctors who are called upon to assess and treat such patients. [ABSTRACT FROM AUTHOR]

Introduction:Patients with cauda equina syndrome (CES) are frequently referred late when neurological damage cannot be reversed. National Guidelines for emergency referral, imaging and treatment of CES contain symptoms and/or signs that are those of late often, irreversible CES. Referral at this stage may be too late for that patient. Methods:Seven sources were reviewed. Advice re emergency referral/imaging/treatment were reviewed. Symptoms/signs were compared with a standard classification of CES. Results:37 recommendations: 12 (32%) were symptoms/signs of bilateral radiculopathy (treatment usually leads to favourable outcomes). Thirteen recommendations (35%) were described in an imprecise way (could be interpreted as early or late CES). Twelve sets of symptoms/signs (32%) were those of late, often irreversible CES where an unfavourable outcome would be expected. Conclusions:Thirty-two percent of the so-called “red flag” symptoms and signs of CES in seven sources were definitely those of late, irreversible CES. These could be seen as “white flags” [flags of defeat and surrender]. Thirty-five percent of the recommendations if interpreted pessimistically (e.g. absent perineal sensation or urinary incontinence) would also be white flags; potentially therefore two-thirds of the so-called “red flag” symptoms/signs of CES could be those of late irreversible CES. Only 32% of the symptoms/signs were true “red flags” i.e. they warn of further, avoidable damage ahead. Guidelines should be redrawn to emphasise referral of patients who are at risk of developing CES or who have early CES. It is illogical for these guidelines to emphasise the clinical features of severe, often untreatable, CES. Demand for emergency MRI will increase; MRI is part of triage and should be performed at the DGH. [ABSTRACT FROM AUTHOR]

Intradural extramedullary spinal infections causing cauda equina compression are uncommon. We report an Escherichia coli bacteraemia causing lumbar discitis and an intracanalicular collection compressing the cauda equina: initially thought to be an epidural empyema, however microsurgery revealed an intradural location. Decompression, drainage, antibiotics, and neuropathy treatment are essential management. [ABSTRACT FROM AUTHOR]

What constitutes cauda equina syndrome (CES), how it should be subclassified and how urgently to image and operate on patients with CES are all matters of debate. A structured review of the literature has led us to evaluate the science and to propose evidence-based guidelines for the management of CES. Our conclusions include this guidance: pain only; MRI negative – recommend: analgesia, ensure imaging complete (not just lumbar spine) adequate follow-up. Bilateral radiculopathy (CESS) with a large central disc prolapse – recommend: discuss with the patient and if for surgery, the next day (unless deteriorates to CESI in which case emergency surgery); CESI – recommend: the true emergency for surgery by day or night; a large central PLID with uncertainty as to whether CESI or CESR (e.g. catheterised prior to CESR) or where there is residual cauda equina nerve root function or early CESR – recommend: treat as an emergency by day or night. Where there has been prolonged CESR and/or no residual sacral nerve root function – recommend: treat on the following day’s list. [ABSTRACT FROM AUTHOR]

Fifty-six human and animal studies of cauda equina syndrome (CES) were reviewed. The evidence from human studies was poor (level IV). Evidence from animal studies and limited evidence from human studies suggest that structural and functional neurological losses are a progressive, continuous process. The longer the cauda equina nerve roots are compressed the greater the harm and the poorer the extent of recovery. This should prompt diagnosis and surgery for all CES patients as soon as practicably possible. [ABSTRACT FROM AUTHOR]

Aims. On-call referrals are a considerable part of the neurosurgical workload. Many neurosurgical centres in the UK have now adopted the practice of maintenance of electronic databases to keep records of on-call activity. We analysed the neurosurgical on-call referrals database maintained at the Newcastle General Hospital (NGH)/Royal Victoria Infirmary (RVI) to assess any trends in the nature of referrals. Methods. Retrospective review and statistical analysis of a contemporaneously populated referrals database, maintained at the Regional Neurosciences Unit in Newcastle. Data were analysed from August 2008 to April 2011. A three point moving average was used to depict trend in the number of referrals. Descriptive statistics were used to display other trends. Analysis was conducted using JMP 8.0.2 (SAS Institute, Cary, NC, USA). Results. Our analysis reveals that the number of emergency referrals to neurosurgery in the North East of England is increasing year-on-year. Mean number of referrals per day has increased by almost 5 over the study period (9.06 in 2008 compared to 13.93 in 2011). The major diagnoses that account for this increase are lumbar degenerative conditions, intracerebral haematomas, spinal trauma and subarachnoid haemorrhage. 50% of the patients are referred out of hours and approximately one-third are admitted. In contrast, 47% of all referrals to rule out a cauda equina syndrome, need admission for scanning. General practitioners (GP) are the single biggest source of referral outside of the parent NHS trust and 47% of the GP referrals are regarding lumbar degenerative conditions and cauda equina syndrome. Conclusions. Continuously increasing referrals have implications on cost, staffing and sustainability of the service. Alternative referral pathways, especially for referrals from primary care, must be considered to restore the on-call workload to 'true' neurosurgical emergencies. [ABSTRACT FROM AUTHOR]

Purpose. This study aims to quantify the value of digital rectal examination (DRE) in the clinical diagnosis of cauda equina syndrome. Methods. A retrospective case note review was performed on all patients referred to a University Teaching Hospital over a one-year period with documented suspicion of cauda equina syndrome. All Patients underwent MRI scanning to either confirm or rule out the diagnosis. Results. Fifty-seven such patients were identified, 13 (23%) of whom had confirmation of cauda equina syndrome on MRI scanning. The DRE did not significantly discriminate for the outcome of MRI (p = 0.897, test accuracy 51%, diagnostic odds ratio 1.42). There was no correlation between the cumulative number of positive clinical findings in an individual patient and the likelihood of MRI diagnosis and no significant link between any individual clinical feature and the MRI result. Conclusions. Digital rectal examination has no significant value in the acute diagnosis of cauda equina syndrome. This study further confirms that there is no discreet clinical protocol applicable with which to confidently confirm or rule out this diagnosis. DRE is traditionally enshrined as an essential facet of clinical assessment in suspected cauda equina syndrome but it cannot be used as a discriminator to ration urgent MRI scanning. [ABSTRACT FROM AUTHOR]

The spinal cord is an extremely rare site for primary central nervous system (CNS) lymphoma (< 1%). Very few cases of primary cauda equina (including conus) lymphoma were previously reported. We report such a case, and with literature review, discuss their clinical features, operative and histopathological findings. Although rare, with an increasing incidence of CNS lymphoma, they should be considered in the differential diagnosis of intradural lesions. Furthermore, with intraoperative smear to establish diagnosis, extensive surgery can be avoided. The controversial role of glucocorticoids in the management of these patients is also discussed. [ABSTRACT FROM AUTHOR]

The article discusses the work of French doctor André Du Laurens, focusing on his depiction of the lower spinal nerves as a horse's tail. Criticisms of Du Laurens' book "Historia anatomica humani corporis" are described, and the author notes Du Laurens' influence on the study of nerves in the spinal chord, highlighting Du Laurens' use of the term "cauda equina" (horse's tail). The relationship of of Du Laurens' use of the metaphor of a horse's tail in anatomy to the use of the term "pony tail" in describing hairstyles is discussed, and the author notes the inception of the pony tail style by British general William Cadogan.

Background: This is a unique report of 40 patients litigating in relation to the management of a cauda equina syndrome (CES), with prospective data collection. Methods: Patients were seen and examined; medical records and radiological imaging were reviewed. The following data were collected prospectively: age; sex; the level of cauda equina (CE) compression; the pathology causing the compression; the clinical picture at first presentation; the causes of any iatrogenic injury; possible breaches of duty of care and the responsible discipline; recovery of bladder control; return to work. Findings: There were possible breaches of duty of care for 39 patients initially, and for 69 patients overall. Twenty-eight patients presented with compressive degenerative pathologies (mainly central disc prolapses); all 28 had deteriorated to the point of bladder paralysis (complete CES (CESR)) at the time of treatment. Twenty-six (93%%) had voluntary bladder control at presentation. Long-term bladder paralysis was probably avoidable in over 90%% of patients. Eleven patients had iatrogenic injuries: all had long-term bladder paralysis. Thirty-four patients had bladder paralysis (CESR) at the point of decompressive surgery. Recovery of bladder function occurred in only seven patients (21%%), i.e. long-term bladder outcomes were poor. Only 22%% of patients returned to work. Conclusion: In this highly selected group of patients whose CES was not managed in an appropriate/standard fashion, 93%% of patients had long-term bladder, bowel and sexual dysfunction that was probably avoidable. Mismanagement of patients with iatrogenic injuries was associated with a universally poor outcome. [ABSTRACT FROM AUTHOR]

Primary germ cell tumors may spread to the lung, liver, brain, and bone hematogenously. However, spinal metastasis is extremely rare. A case with yolk sac tumor (YST) and cauda equina metastasis was presented in a 2-year-old boy. Two months prior to admisssion, he underwent left radical orchiectomy for testicular YST. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed spinal and cauda equina involvement. This is the first report of metastasis of testicular YST to cauda equina in a child. [ABSTRACT FROM AUTHOR]

A logical, rational and reasonable guideline for the management of patients with suspected cauda equina syndrome (CESS) is proposed. This article is intended to promote debate. Ideally spinal surgeons can agree a standard of care that can be applied nationally to the benefit of our patients, our colleagues and, as neurosurgeons and spinal surgeons, ourselves. [ABSTRACT FROM AUTHOR]

Cauda equina syndrome (CES) is a neurological syndrome presenting with non-specific symptoms and signs that often leads to diagnostic confusion and delay. Acute onset CES is a surgical emergency. The common aetiology is a prolapsed lumbar disc. If the diagnosis is missed, it can have devastating consequences for the patient and a high financial cost to healthcare providers. The objective of this study was to evaluate the efficacy of clinical assessment in clinching the diagnosis. Eighty patients who underwent urgent clinical assessment and magnetic resonance imaging (MRI) for suspected CES over a 1-year period (from January 1st 2008 to 31 December 2008) were included in the study. Fifteen of these patients had a CES and underwent urgent lumbar discectomy and decompression. Medical notes and MRI scans of all these patients were reviewed. The presenting symptoms and signs were analysed against a positive MRI scan. Chi-square test with Yates correction was used to test association of each clinical symptom and sign for a positive MRI. In this study, only 18.8% of assessed patients had a CES producing compression seen on the MRI. Presence of saddle sensory deficit was the only clinical feature with a statistically significant association with MRI positive CES ( p = 0.03). This series shows that saddle sensory deficit has a higher predictive value than other clinical features in diagnosing a CES. However, as there is no symptom or sign which has an absolute predictive value in establishing the diagnosis of CES, any patient in whom a reasonable suspicion of CES arises must undergo urgent MRI to exclude this diagnosis. [ABSTRACT FROM AUTHOR]

Spinal cauda equina lymphoma (CEL) is very rare, with only about 14 cases reported in the English medical literature. Magnetic resonance image findings and the gross appearance of CEL at surgery are similar to those of non-neoplastic hypertrophic neuropathy of the cauda equina (HNCE); however, their prognosis and treatment are very different. We report a case of CEL and discuss the differences from non-neoplastic HNCE. [ABSTRACT FROM AUTHOR]

The article reviews the article "Degenerative Lumbosacral Stenosis in Working Dogs: Current Concepts and Review," by A. J. Worth, D. J. Thompson and A. C. Hartman, which appeared in the periodical "New Zealand Veterinary Journal" in December 2009.

Child cauda equina leptomeningitis (CCEL) is a typical clinical example of aseptic meningitis with patterns of an emerging disease, and it affects children aged 2-9. Here we will describe six cases of CCEL. After the prodromes, all children underwent an acute phase with hypoasthenia of the lower limbs, hyporeflexia, staggering and ataxia with steppage. Only in one case there were generalized fits and coma of grade 1-2 too. All children underwent a spinal Magnetic Resonance Imaging (MRI), proving pathologic enhancement of cauda equina and conus medullaris leptomeningitis. At the same time, MRI made possible the differential diagnosis between cauda equina leptomeningitis and isolated minor forms of Guillain-Barre syndrome involving the lower limbs. Three hypotheses will be formulated for understanding the pathogen mechanism(s) of CCEL. The first one is based on the presence of an immediate viral damage on the meninges, the second one, the more likely, contemplates the occurrence of an immunomediated mechanism in a host genetically prone to react in an abnormal way from an immune viewpoint. The third hyphotesis consists in a two-time damage: an early immediate damage from the virus, and a later immunomediated reaction. [ABSTRACT FROM AUTHOR]

The last decade has witnessed a resurgence of interest in the surgical treatment of metastatic spinal disease to compliment radiotherapy. A recent randomized controlled trial looking directly at this issue concluded strongly in favour of a combination of surgical decompression and radiotherapy, and there is now growing enthusiasm for surgery to play a role in the management of these patients. We present a prospective cohort study of 62 patients who presented with metastatic cord or cauda equina compression, and were treated with surgical decompression and fixation where necessary. Patients were treated by one surgeon working in a single unit. They were followed-up long term and were assessed objectively, by clinical assessment and prospective questionnaires that included SF36, visual analogue pain scores and Roland Morris back pain scores. Sixty-two patients with a median age of 62 (22 - 79 years, 27 male) were included in the study. The commonest primary tumours were breast (26%) and lymphoma (13%). The majority of patients had involvement of thoracic vertebrae (58%). 56% of patients were alive at 1 year and 28% at 3 years, with significant improvements observed in both walking and continence. Similarly, significant improvements were seen in SF36 quality of life scores as well as pain. With careful patient selection, long-term survival and good quality of life can be achieved. However, not every patient is suitable or appropriate for surgery, and the discussion focuses on where the surgical threshold should be set. [ABSTRACT FROM AUTHOR]

Spinal canal endoscopy is recognised as a new technique for treatment of chronic low back and leg pain due to lumbar epidural adhesions involving nerve roots. In this paper, the cases of two patients who received orthopaedic surgery combined with spinal canal endoscopy are discussed. In case 1, the patient had a cauda equina tumour and underwent extirpation of the tumour assisted by spinal canal endoscopy. In case 2, the patient was suffering from extensive epidural abscess. He was treated with antibiotics and underwent single-level laminectomy and drainage assisted by spinal canal endoscopy. In case 1, small tumours that could not be identified by magnetic resonance imaging were identified with spinal canal endoscopy: the tumours were then partially removed from the T12 vertebral level to the S1 vertebral level by right hemilaminectomy of S1, and laminectomy of L5 and T12. In case 2, the use of spinal canal endoscopy enabled drainage and lavage of the wide lesion of the abscess by the single–level laminectomy and a minimally invasive operation. Spinal canal endoscopy, a new, diagnostic and therapeutic technique, may be useful not only for low back pain and leg pain but also for strategic treatment of cauda equina tumours and epidural abscess. [ABSTRACT FROM AUTHOR]

This article investigated the time response of COX II induction by traction of the cauda equina assessed by a quantified RT-PCR method. Under deep GOI anesthesia, male Wistar rats were fixed in the prone position and a laminectomy of the dorsal part of the first and second sacral vertebrae was performed. Following, COX II-mRNA levels in the cervical, thoracic, lumbar, sacral, and caudal segments were measured at 2, 4, 6, and 24 h after traction by a quantified RT-PCR method. After cauda equina traction, significant levels of COX II mRNA were detected in all segments of the spinal cord examined. Maximum levels in each segment were determined 4 h after traction of the cauda equina. Particularly in the sacrocaudal segments significantly higher levels of COX II mRNA were measured 24 h after traction. These results indicate that significant induction of spinal COX II mRNA was caused by cauda equina traction and that such induction plays a regulatory role in the nociceptive pain pathway. [ABSTRACT FROM AUTHOR]

The article discusses the influence of the timing of surgery in case of Cauda equina syndrome(CES) on the outcome of the surgery. Patients suffering from CES require decompressive surgery but the controversy is, when to perform surgery. The outcomes of surgery performed on different patients at different timings are explained. The data presented in the article suggests that treatment less than 24 hours after the onset of CES is approximately five times more likely to be associated with the recovery of bladder function than treatment after 24 hours. One of the methods used in the research involved meta-analysis.

An ethically challenging clinical case is presented regarding a 72-year-old man with prostate cancer followed by a palliative care service for severe pain related to sacral bone metastasis and an associated cauda equina syndrome. Subsequent disease progression was associated with increasing pain. He underwent several surgical procedures as well as radiation and multiple cytotoxic chemotherapeutic regimens. The patient's pain was treated aggressively including the placement of an intrathecal pump, and a myelotomy. The ethical questions raised by this case included whether interventional pain management did more harm than good, whether emotional distress was treated inappropriately and whether the driving force of pain was the tumor or existential distress? Three distinguished pain specialists from different disciplinary perspectives comment on his management, with an emphasis on the ethical challenges his care presents. [ABSTRACT FROM PUBLISHER]

We report a case of cauda equina syndrome following attempted spinal anaesthesia in a patient who had a history of a vague low back pain lasting several weeks. It was postoperatively determined that a sequestrated disc was compressing the cauda equina fibres. We suggest that previously undiagnosed disc herniation may reveal itself or even progress further during a neuroaxial anaesthesia attempt. [ABSTRACT FROM AUTHOR]