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BACKGROUND: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

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 is a surgical emergency caused by the compression of the lumbosacral nerves. The most frequent cause is discal herniation, while tumoral pathology in this region is rare, and congenital processes are less common. We report the case of a young 37-year-old male patient, admitted to the emergency room with an incomplete cauda equina syndrome. As medical history, a lumbar surgery 15 years ago was reported with no documentation. An MRI was performed, revealing a mass within the filum terminal exhibiting three components suggestive of a dermoid cyst accompanying a split cord malformation, which was confirmed by pathology. Various disorders may be associated to intradural dermoid cyst, such as lipoma, low-lying cord, hydromyelia or thick filum. Surgery is the treatment of choice, and MRI plays a crucial role in detecting associated abnormalities and determining surgery priorities. [ABSTRACT FROM AUTHOR]

Background: Spinal cord lymphomas represent a minority of extranodal lymphomas and often pose diagnostic challenges by imitating primary spinal tumors or inflammatory/infective lesions. This paper presents a unique case of primary cauda equina lymphoma (PCEL) and conducts a comprehensive review to delineate the clinical and radiological characteristics of this rare entity. Case Report: A 74-year-old male presented with progressive paresthesia, motor weakness, and symptoms indicative of cauda equina syndrome. Neurological examination revealed paraparesis and sphincter dysfunction. Imaging studies initially suggested an intradural meningioma. However, surgical intervention revealed a diffuse large B-cell lymphoma infiltrating the cauda equina. Findings: A systematic review of the pertinent literature identified 18 primary cauda equina lymphoma cases. These cases exhibited diverse clinical presentations, treatments, and outcomes. The mean age at diagnosis was 61.25 years for women and 50 years for men, with an average follow-up of 16.2 months. Notably, 35% of patients were alive at 18 months, highlighting the challenging prognosis associated with PCEL. Discussion: Primary spinal cord lymphomas, especially within the cauda equina, remain rare and diagnostically complex due to their nonspecific clinical manifestations. The review highlights the need to consider spinal cord lymphoma in patients with neurological symptoms, even without a history of systemic lymphoma. Diagnostic Approaches: Magnetic resonance imaging (MRI) serves as the primary diagnostic tool but lacks specificity. Histopathological examination remains the gold standard for definitive diagnosis. The review underscores the importance of timely biopsy in suspected cases to facilitate accurate diagnosis and appropriate management. Management and Prognosis: Current management involves biopsy and chemotherapy; however, optimal treatment strategies remain ambiguous due to the rarity of PCEL. Despite aggressive therapeutic interventions, prognosis remains poor, emphasizing the urgency for enhanced diagnostic and treatment modalities. Conclusions: Primary cauda equina lymphoma poses diagnostic and therapeutic challenges, necessitating a high index of suspicion in patients with atypical spinal cord symptoms. Collaborative efforts between neurosurgical, oncological, and infectious diseases teams are imperative for timely diagnosis and management. Advancements in diagnostic precision and therapeutic options are crucial for improving patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Measuring elevated post-void residual volume is important for diagnosing urinary outflow tract obstruction and cauda equina syndrome. Catheter placement is exact but painful, invasive, and may cause infection, whereas an ultrasound is accurate, painless, and safe. Aim: The purpose of this single-center study is to evaluate the accuracy of a module for artificial-intelligence (AI)-based fully automated bladder volume (BV) prospective measurement using two-dimensional ultrasound images, as compared with manual measurement by expert sonographers. Methods: Pairs of transverse and longitudinal bladder images were obtained from patients evaluated in an urgent care clinic. The scans were prospectively analyzed by the automated module using the prolate ellipsoid method. The same examinations were manually measured by a blinded expert sonographer. The two methods were compared using the Pearson correlation, kappa coefficients, and the Bland–Altman method. Results: A total of 111 pairs of transverse and longitudinal views were included. A very strong correlation was found between the manual BV measurements and the AI-based module with r = 0.97 [95% CI: 0.96–0.98]. The specificity and sensitivity for the diagnosis of an elevated post-void residual volume using a threshold ≥200 mL were 1.00 and 0.82, respectively. An almost-perfect agreement between manual and automated methods was obtained (kappa = 0.85). Perfect reproducibility was found for both inter- and intra-observer agreements. Conclusion: This AI-based module provides an accurate automated measurement of the BV based on ultrasound images. This novel method demonstrates a very strong correlation with the gold standard, making it a potentially valuable decision-support tool for non-experts in acute settings. [ABSTRACT FROM AUTHOR]

Neurosarcoidosis (NS) with hypothalamic-pituitary (HP) involvement (HP-NS) is a rare clinical condition, conferring variable hormonal deficits that are typically irreversible. Here, we present 2 cases of NS with panhypopituitarism. The first patient presented with cauda equina syndrome and arginine vasopressin deficiency, while the second developed recurrent optic neuritis and vision loss in the setting of a sellar mass. In the first case, neurological symptoms resolved after therapy with high-dose glucocorticoids, infliximab, and methotrexate; while in the second, visual restoration followed resection of the granulomatous tissue and immunosuppressive therapy. In both cases, pituitary dysfunction persisted despite neurological improvement. We contextualized the presentations and outcomes through a literature review of HP-NS case reports and case series. This revealed high rates of extraneurologic sarcoidosis in HP-NS patients with panhypopituitarism, while underscoring the need for hormonal replacement--as endocrinopathies rarely respond to sarcoidosis-directed immunosuppression. [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]

To report the first case of hyperacute onset of adjacent segmental disease (ASD) with dorsally migrated herniated nucleus pulposus (HNP) causing cauda equina syndrome. A 55-year-old female complained of lower back pain with radiating pain in both lower extremities that had not responded to conservative treatment over the previous six months. Plain radiographs and magnetic resonance imaging (MRI) findings revealed degenerative spondylolisthesis with spinal stenosis at L3–4, L4–5, and a slight bulging disc at L2–3. The patient underwent decompressive total laminectomy and posterior fusion at L3–4 and L4–5. The stenotic symptoms improved significantly after surgery, and she was then discharged on postoperative day 7. However, the patient visited the emergency department four days after discharge (postoperative day 11) complaining of sudden onset of bilateral lower extremity weakness and voiding and defecation difficulties. The follow-up MRI showed dorsally migrated huge HNP and a detached posterior longitudinal ligament (PLL) at L2–3, which was diagnosed as hyperacute onset of ASD causing cauda equina syndrome. The patient underwent an emergency second operation consisting of partial laminectomy at L2–3 with removal of the dorsally migrated huge HNP. After the second operation, the symptoms of cauda equina syndrome improved. One year after the second operation, the patient is doing well without recurrence of symptoms. Our case showed that hyperacute onset of ASD with dorsally migrated huge HNP can cause cauda equina syndrome, even within 2 weeks after lumbar fusion surgery. Therefore, a high index of suspicion, timely diagnosis, and surgical treatment are needed to avoid the catastrophic neurologic complications in similar extremely rare cases. [ABSTRACT FROM AUTHOR]

Diagnosis of low back pain can be intriguing and complex. Careful history-taking and physical examination are essential to ensure red flags (serious issues) are not missed, that treatment is appropriate, evidence-based and timely, and that follow-up and review are well documented and understood by the patient. This article covers some of the more common causes of back pain in primary and urgent care. [ABSTRACT FROM AUTHOR]

Radiculopathy is a commonly encountered symptom in neurosurgical practice. This article discusses the clinical presentation, anatomy, pathophysiology and treatment of radiculopathy, neurogenic claudication and cauda equina syndrome. [ABSTRACT FROM AUTHOR]

Introduction: Cauda Equina Syndrome (CES) is one of the genuine orthopaedic emergencies. Diagnosis of acute CES is challenging and may be missed, resulting in considerable medicolegal claims. In Ireland, nearly €21 million in compensation has been paid out over a 10-year period due to the diagnosis being missed. As a result, defensive practices have resulted in an increased number of referrals for CES to the on-call orthopaedic service in a major trauma unit. Methods: A prospective data-capturing exercise was carried out of all referrals for acute CES to the orthopaedic on-call department in a tertiary-level university-affiliated teaching hospital between August and November 2023. Qualitative data was captured including referral source, referring clinician grade, in-hours or out-of-hours referral, MRI on referral, red flags as identified by the referring team, red flags as identified by the orthopaedic team, and outcome. Results: Forty referrals for CES were made over the duration of this audit. Seventeen (42.5%) referrals were made in-hours, and 23 (57.5%) were referred out-of-hours. Only five (12.5%) of these referrals had an MRI done at the time of the referral. No patients were transferred for an out-of-hours MRI to another hospital. Only five (12.5%) patients required surgical decompression—none of these patients required an out-of-hours emergent decompression. Conclusion: There is a lack of understanding as to what exactly is being referred—resulting in a referral volume which is over ten times the expected number of CES cases being made to our unit. The lack of out-of-hours MRI access poses a significant concern for patient outcomes. [ABSTRACT FROM AUTHOR]

The cauda equina syndrome (CES) is a rare but critical disorder, which can result in devastating motor weakness and sensory deficit, alongside often irreversible bladder, bowel and sexual dysfunction. In addition to the clinical burden of disease, this syndrome results in a disproportionately high medicolegal strain due to missed or delayed diagnoses. Despite being an emergency diagnosis, often necessitating urgent surgical decompression to treat, we believe there is a lack of clarity for clinicians in the current literature, with no published Irish guideline concerning screening or detection. The current study aims to identify and analyse appropriate guidelines in relation to CES screening which are available to clinicians in Ireland. The study design included a comprehensive literature review and comparison of existing guidelines. The review identified 13 sources of appropriate guidance for clinicians working in Ireland. These resources included textbooks, websites and guidelines developed in the UK. No Irish guidelines or advice were available on CES screening/treatment at the time of review. This review demonstrated the lack of consensus and guidance for clinicians in Ireland on how to effectively screen for CES, judge who requires further imaging and investigations and how to rule out the condition. A national consensus on thorough screening and prompt investigation for CES is necessary, and the formulation of new CES guidelines would be a welcome addition to what is available to clinicians currently. [ABSTRACT FROM AUTHOR]

This document contains abstracts from the 10th SICCR National Congress, covering various topics related to colorectal surgery. The abstracts provide brief summaries of studies and presentations on topics such as the use of chlorphenamine as a substitute for opioids in sedating patients during colonoscopy, risk factors for mortality and complications in colorectal cancer surgery, different surgical approaches for rectal cancer, and outcomes of laparoscopic surgery for colon cancer. The studies emphasize the importance of individualized treatment plans and multidisciplinary approaches for optimal outcomes. The document also includes abstracts on other proctological conditions and procedures, such as hemorrhoids and anal fistulas. [Extracted from the article]

Purpose: Mebos, a traditional South Africa confection consisting of dried, pulped, and sugared apricots, is rich in fibre and vitamins, but also contains salicylic acid, flavonoids, and citric acid. We report a case of postoperative surgical site bleeding in a healthy patient who consumed approximately 2 kg of mebos per day prior to his elective spinal surgery. Methods: The clinical course of a previously healthy 54-year-old male patient with cauda equina syndrome secondary to lumbar spinal stenosis who underwent surgical intervention with subsequent bleeding into the surgical site is discussed. The cause was investigated through biochemical analysis, thromboelastometry (ROTEM®) and mass and absorption spectrometry were applied to assess flavonoid, citric acid, and salicylic acid content. Results: ROTEM® revealed an abnormal clotting profile with an increased clot forming time, suggesting intrinsic coagulopathy. Mass and absorption spectrometry revealed a high total flavonoid content as well as citric acid concentration in the mebos. Salicylic acid was at detection limits of the instrument. Conclusion: Results highlighted the effect of flavonoids and citric acid and therefore explain the abnormal clotting profile in this patient. Inhibition of coagulation prior to elective surgery is a known contraindication and may pose great risks in spinal surgery. In the present report, we demonstrated an association between inhibition of coagulation and an excess of the flavonoids content and citric acid concentration in mebos consumed in the days prior to elective spinal surgery. [ABSTRACT FROM AUTHOR]

Purpose: To report a unique case of incomplete CES following a rebar penetrating injury in perineal region with retro-pulsed fragment, which was treated with anterior approach and discuss suitable surgical approach. Methods: Incomplete cauda equina syndrome caused by non-missile penetrating injury is extremely rare. A 26-year-old male patient presented incomplete cauda equina syndrome due to a penetrating rebar wound from his perineal region to the lumbosacral spine. Computed tomography demonstrated a bony fragment broken from S1 body compressing into the spinal canal. Results: By anterior approach, we performed partial corpectomy of L5, decompression by retrieving the bony fragment and L5-S1 interbody fusion. The patient had a significant recovery, and no clinical complication was found after over 2-year follow-up. Conclusion: It is challenging to determine the optimal strategy of surgical treatment for penetrating spinal injuries with retained foreign bodies, here we suggest an anterior approach situation that has the advantage of being able to effectively perform decompression and prevent iatrogenic damages of thecal sac and nerve rootlets. [ABSTRACT FROM AUTHOR]

Study Design: This was a systematic review of surgically managed Cauda Equina Syndrome (CES) Outcome Measurement Instruments (OMI). Objective: A core outcome set (COS) defines agreed outcomes which should be reported as a minimum in any research study for a specific condition. This study identified OMIs used in the wider CES literature and compare these to the established CESCOS. Methods: To identify measurement methods and instruments in the CES surgical outcome evidence base, a systematic review was performed. Medline, Embase and CINAHL plus databases were queried. In addition, a secondary search for validation studies of measurement instruments in CES was undertaken. Identified studies from this search were subject to the COSMIN risk of bias assessment. Results: In total, 112 studies were identified investigating surgical outcomes for CES. The majority (80%, n = 90) of these OMI studies were retrospective in nature and only 55% (n = 62) utilised a measurement method or instrument. The remaining 50 studies used study specific definitions for surgical outcomes defined within their methods. Of the 59 measurement instruments identified, 60% (n = 38 instruments) were patient reported outcome measures. Only one validated instrument was identified, which was a patient reported outcome measure. The validated instrument was not used in any study identified in the initial search (to identify measurement instruments). Conclusions: This review highlights the wide heterogeneity of measurement instruments used in surgically managed CES research. Subsequently, there is need for consensus agreement on which instrument or instruments should be used to measure each core outcome for CES surgical outcomes. [ABSTRACT FROM AUTHOR]

Abstract Cauda equina syndrome is a surgical emergency caused by the compression of the lumbosacral nerves. The most frequent cause is discal herniation, while tumoral pathology in this region is rare, and congenital processes are less common. We report the case of a young 37-year-old male patient, admitted to the emergency room with an incomplete cauda equina syndrome. As medical history, a lumbar surgery 15 years ago was reported with no documentation. An MRI was performed, revealing a mass within the filum terminal exhibiting three components suggestive of a dermoid cyst accompanying a split cord malformation, which was confirmed by pathology. Various disorders may be associated to intradural dermoid cyst, such as lipoma, low-lying cord, hydromyelia or thick filum. Surgery is the treatment of choice, and MRI plays a crucial role in detecting associated abnormalities and determining surgery priorities.

Pneumorrhachis (PR) is an uncommon condition characterized by the accumulation of air within the spinal canal. This finding may occur due to various causes, mostly after trauma and medical procedures. It can manifest with various features depending on the underlying cause, the location, and the extent of the air trapped. Clinically, the symptoms in affected patients can span a spectrum, ranging from being asymptomatic to manifesting as radiculopathies resulting from compression. The pneumorrhachis-related cauda equina syndrome is incredibly rare and typically appears as a large volume of air causing compression or irritation of the nerve roots in the lower spinal cord. In this report, we present a female patient whose cauda equina syndrome developed as a result of accidental extradural pneumorrhachis after epidural injection in the lumbar spine.

Background: Lumbar disc surgery is among the more common spinal procedures. In this paper, we report the current treatment recommendations for patients with symptomatic disc herniation. Methods: This review is based on pertinent publications retrieved by a selective literature search in PubMed using the terms [timing] AND [lumbar disc herniation], supplemented by other relevant articles and guidelines. Results: Symptoms resolve in 60% to 80% of patients with herniated discs in 6--12 weeks, and in 80% to 90% over the long term (≥ 1 year). According to the guidelines, 6--12 weeks of conservative treatment are recommended in the absence of significant neurologic deficits. Early surgery is indicated in case of worsening pain or new onset of neurologic deficits. Lumbar disc herniation associated bladder or bowel dysfunction (cauda equina syndrome) is considered an absolute surgical emergency that requires immediate decompression (within 24 to 48 hours). Patients with severe motor deficits (MRC ≤ 3/5) benefit from early intervention and should be offered surgery within three days, if possible, for the best chance of recovery. The degree of weakness and the duration of symptoms have been identified as risk factors for incomplete recovery. Early surgery can be considered in patients with mild paresis (MRC 4/5) in case of functional impairment (e.g., quadriceps paresis). Conclusion: Longer symptom duration and lower motor scores are associated with worse outcome and a lower chance of neurologic recovery. The recovery rate for motor deficits ranges from 33% to 75%, depending on the timing and modality of treatment as well as the motor score. [ABSTRACT FROM AUTHOR]

Unstable traumas of the spinopelvic junction, which include displaced U-shaped sacral fractures (Roy-Camille type 2 and type 3) and Tile C vertical shear pelvic ring disruptions, occur in severe traumas patients following high speed traffic accident or fall from a height. These unstable traumas of the spinopelvic junction jeopardize one's ability to stand and to walk by disrupting the biomechanical arches of the pelvis, and may also cause cauda equina syndrome. Historically, such patients were treated with bed rest and could suffer a life-long burden of orthopedic and neurological disability. Since Schildhauer pioneer work back in 2003, triangular spinopelvic fixation, whether it is performed in a percutaneous fashion or by open reduction and internal fixation, allows to realign bone fragments of the spinopelvic junction and to resume walking within three weeks. Nevertheless, such procedure remains highly technical and it not encountered very often, even for spine surgeons working in high-volume level 1 trauma centers. Hence, this visual technical note aims to provide a few tips to guide less experience surgeons to complete this procedure safely. [ABSTRACT FROM AUTHOR]

This article presents a case study of a patient who underwent a surgical procedure to treat a thoracolumbar burst fracture with neurological deficit. The surgery involved the use of pedicle screw distraction fixation and expandable jack implant kyphoplasty to restore spinal alignment and decompress the spinal canal. The patient experienced improvements in motor strength and was able to walk without assistance after the surgery. The authors suggest that this surgical technique is an effective and minimally invasive approach to treating lumbar burst fractures with neurological deficits. [Extracted from the article]

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]

The first abstract discusses a study on the effects of a mindfulness-based stress reduction program on patients with Parkinson's disease. The program was found to improve psychological distress and quality of life, indicating potential benefits for individuals with Parkinson's disease. The second abstract explores the relationship between sleep disturbances and cognitive function in Parkinson's disease patients, finding that sleep disturbances are associated with poorer cognitive function, particularly in attention and executive function. The third abstract focuses on a study that found a virtual reality-based exercise program to significantly improve balance and gait in individuals with Parkinson's disease. The fourth abstract discusses the positive effects of a dance intervention on motor and non-motor symptoms in Parkinson's disease patients, including improvements in motor symptoms, depression, and anxiety. The fifth abstract examines the effects of a cognitive training program on cognitive function in individuals with Parkinson's disease. [Extracted from the article]

Cauda equina syndrome (CES) is a surgical emergency that often leads to debilitating chronic neuropathic pain, lower limb paralysis, loss of both faecal and urinary continence, and loss of sexual function; all of which cause a large degree of morbidity often causing psychological issues in the patient and a strain on family and their personal relationships. It is usually caused by a space occupying lesion in the lumbrosacral spinal canal causing a compressive mass effect on the peripheral nerve fibres of the cauda equina. This causes a syndrome of lower back pain, sciatica type symptoms, sensory and motor power loss of the lower limbs and perineum including loss of bladder or bowel control. Fortunately, it is relatively uncommon – affecting 1–3 per 100,000 people in England. Suspected CES as a presentation is vastly more common with about 8000 cases a year in England. It is a time-sensitive condition and as such early diagnosis and management of CES is a priority to prevent disability. When CES is diagnosed, it requires an emergency operation to decompress the cauda and prevent long-term disability. [ABSTRACT FROM AUTHOR]

Background: Aside from the rarity of mobile spinal schwannomas, the coexistence of these tumors with herniated intervertebral disc is also scarce. Furthermore, cauda equina syndrome (CES), as a manifestation of intraspinal schwannomas has been reported rarely. Described here is a case of simultaneous lumbar disc bulge and mobile spinal schwannoma presented with intermittent symptoms of CES. Case Report: A 62-year-old man presented with severe but intermittent leg pain for 2 weeks, which later progressed to an episode of lower extremity weakness and difficulty in urination. Magnetic resonance imaging revealed an intraspinal tumor that moved in position relative to the L1-2 disc bulge on scans 6 h apart, with associated spontaneous regression in symptoms. The tumor was found to be a mobile spinal schwannoma, originated from a nerve root. A standard microdissection technique was used to remove the tumor through a spinous processsparing unilateral approach, with complete laminectomy of L1. Use of intraoperative ultrasound facilitated the accurate tumor localization. Postoperatively, the patient no longer had symptoms. Conclusions: This report presents a combination of a common spinal pathology, intervertebral disc herniation, alongside a rare condition, mobile spinal schwannoma, whose uncommon clinical manifestations, such as CES can cause irreversible neurological deficits. Surgeons need to remain vigilant of potential atypical scenarios when treating patients. Surgical treatment challenges regarding the mobility of tumors, such as accurate localization, should be addressed using intraoperative imaging to avoid wrong-level surgery. To mitigate the irreversible neurological complications, patients should receive comprehensive information for alarming signs of CES. [ABSTRACT FROM AUTHOR]

In this case report, we describe an uncommon case of neuroendocrine cancer of unknown origin began with cauda equina syndrome in a patient affected by Paget disease of bone (PDB). A 76-year-old man with diagnosis of PDB, without history of pain or bone deformity, developed sudden severe low back pain. Bone alkaline phosphatase was increased and MRI and whole-body scintigraphy confirmed the localization of the disease at the third vertebra of the lumbar spine. Treatment with Neridronic Acid was started, but after only 2 weeks of therapy anuria and bowel occlusion occurred together with lower limb weakness and walking impairment. Cauda equina syndrome consequent to spinal stenosis at the level of L2–L3 was diagnosed after admission to Emergency Department and the patient underwent neurosurgery for spinal medulla decompression. The histologic results showed a complete subversion of bone structure in neoplastic tissue, consistent with metastatic neuroendocrine carcinoma of unknown origin. In conclusion, low back pain in the elderly may require deep investigation to individuate rare diseases. In asymptomatic patients with apparently stable PDB, the sudden appearance of pain or neurologic symptoms may alert the clinician for the possibility of other superimposing diseases, like bone metastases. [ABSTRACT FROM AUTHOR]

Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high‑risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration. [ABSTRACT FROM AUTHOR]

This article discusses the diagnosis and treatment of spontaneous acute-onset conus medullaris or cauda equina syndrome caused by spinal acute subdural hematoma. The condition is rare and challenging to diagnose, but prompt diagnosis and emergency surgical decompression are necessary due to the serious nature of the disease. The article presents a case study of a 67-year-old male patient who underwent surgical evacuation of the hematoma and experienced a favorable neurological outcome. The article also discusses the etiology, clinical presentation, and management of spinal acute subdural hematoma, emphasizing the importance of surgical decompression for patients with neurological deficits. [Extracted from the article]

A rare case of aneurysm of the lateral sacral artery is reported. This 46-year-old female presented with complaints of bowel and bladder incontinence and decreased perianal sensation for the past 15 months. She underwent laminectomy and diskectomy for the diagnosis of a prolapsed disk at peripheral hospital where the surgeon was confronted with a severe and unexpected hemorrhage, and surgery was aborted without effective treatment. Prior medical history includes hypertensive kidney disease with a renal transplant eight years ago. Magnetic resonance imaging and angiographic findings were suggestive of a lateral sacral artery aneurysm. Patient with a history of renal transplant and presenting with cauda equina require a more thorough assessment, and a differential of lateral sacral artery aneurysm should always be kept in mind. Our purpose is to report the pre-operative features of the lateral sacral artery aneurysm and its treatment modalities. [ABSTRACT FROM AUTHOR]

Introduction: Optimal management of transverse sacral fractures (TSF) remains inconclusive. These injuries may present with neurological deficits including cauda equina syndrome. We present our series of laminectomy for acute TSF with cauda equina compression. Methods: This was a retrospective chart review of all patients that underwent sacral laminectomy for treatment of cauda equina compression in acute TSF at our institution between 2007 through 2023. Results: A total of 9 patients (5 male and 4 female) underwent sacral laminectomy to decompress the cauda equina in the setting of acute high impact trauma. Surgeries were done early within a mean time of 5.9 days. All but one patient had symptomatic cauda equina syndrome. In one instance surgery was applied due to significant canal stenosis present on imaging in a patient with diminished mental status not allowing proper neurological examination. Torn sacral nerve roots were repaired directly when possible. All patients regained their neurological function related to the sacral cauda equina on follow up. The rate of surgical site infection (SSI) was 33%. Conclusion: Acute early sacral laminectomy and nerve root repair as needed was effective in recovering bowel and bladder function in patients after high impact trauma and TSF with cauda equina compression. A high SSI rate may be reduced by delaying surgery past 1 week from trauma, but little data exists at this time for clear recommendations.

This article provides information on the physiological and behavioral considerations for managing horses with tail disorders. The horse's tail serves various purposes, including communication, temperature regulation, and protection. Different tail disorders can occur in horses, and treatment options depend on the specific injury. The article also discusses the practice of tail docking in horses and argues that there are no documented benefits for horses in tail docking, emphasizing the importance of preserving the tail for their well-being. [Extracted from the article]

This article discusses the case of a patient who experienced progression of disc herniation after receiving a transforaminal epidural steroid injection (TFESI) for low back and leg pain. The patient initially had a positive response to the injection, but two days later, she reported increased pain and difficulty walking. An MRI revealed an increase in the size of the herniation. The article suggests that further research is needed to determine if this is a possible side effect of the treatment. [Extracted from the article]

Abstract 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.

Cauda equina syndrome (CES) is a severe neurological condition with potentially high morbidity. Patients usually present with varying degrees of neurological deficit, especially sphincter dysfunction, which needs to be diagnosed early and correctly indicated for surgical treatment. Our retrospective study is focused on the determination of different prognostic factors and their impact on the final neurological outcome of patients with CES. Forty-four CES patients were recruited in the study. The duration of symptoms has proven to be a statistically significant factor in improving the clinical condition. Patients with a shorter medical history of neurological symptomatology had a better neurological outcome. Also, there was a positive relationship between the initial and outcome score, i.e., the outcome status is related to the severity of the neurological deficit on admission. The remaining factors appeared to be statistically insignificant. [ABSTRACT FROM AUTHOR]

Pain can occur after any spinal surgery. Despite this, there are other many signs and symptoms of neurological deficits that can occur in patients with varying severity. Our aim is to find some of the main neurological deficits that can occur after any spinal surgery. We searched the literature based on some of the important keywords like neurological deficits after spine surgery, foot drops, cauda equina syndrome, epidural hematoma, and nerve and dural injury. Based on this we analyzed the most important and widely read articles. The problems associated with spine surgery have been published in the literature but are much more than the failed back surgery syndrome and cause more discomfort to patients with varying degrees of neurological deficits. We have coined a new term "Extended Post-spinal Surgery Syndrome (EPSS)" for these conditions. We propose this to include the other complications after lumbar surgery including nerve injury, dural injury, cauda equina syndrome and epidural haematoma. [ABSTRACT FROM AUTHOR]

Background: Symptoms of cauda equina syndrome (CES) secondary to degenerative lumbar spine diseases are sometimes mild and tend to be ignored by patients, resulting in delayed treatment. In addition, the long-term efficacy of surgery is unclear. Objective: To determine the predictive factors of CES and post-operative recovery in patients with symptoms lasting > 3 months. Methods: From January 2011 to December 2020, data of 45 patients with CES secondary to lumbar disk herniation/lumbar spinal stenosis were collected from a single center. The patients had bladder, bowel or sexual dysfunction and decreased perineal sensation that lasted for > 3 months. A 2-year post-operative follow-up was conducted to evaluate recovery outcomes, which were measured by validated self-assessment questionnaires conducted by telephone and online. Results: Overall, 45 CES patients (57.8% female; mean age, 56 years) were included. The duration of pre-operative CES symptoms was 79.6 weeks (range, 13–730 weeks). The incidence of saddle anesthesia before decompression was 71.1% (n = 32), bladder dysfunction 84.4% (n = 38), bowel dysfunction 62.2% (n = 28) and sexual dysfunction 64.4% (n = 29). The overall recovery rate of CES after a 2-year follow-up was 64.4%. The rates of the residual symptoms at the last follow-up were as follows: saddle anesthesia 22.2%, bladder dysfunction 33.3%, bowel dysfunction 24.4% and sexual dysfunction 48.9%. Pre-operative saddle anesthesia, overactive bladder and sexual dysfunction were risk factors for poor prognosis after decompression. Conclusion: CES patients with symptoms lasting > 3 months may recover after surgery. Sexual dysfunction has a high residual rate and should not be ignored during diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Neurophobia is well recognized as dissuading medical students from neurocentric specialties and limiting the success of neurology and neurosurgery teaching at medical school. Past studies have associated neurophobia with deficiencies in medical education. We performed a cross-sectional analysis of medical students' confidence and perceived level of knowledge in recognizing the following neurosurgical and neurological emergencies: ischemic stroke, hemorrhagic stroke, status epilepticus, subarachnoid hemorrhage, increased intracranial pressure, acute hydrocephalus, spinal cord injury, cauda equina syndrome, and traumatic brain injury. In addition, we assessed the usefulness of virtual seminars in neurosurgery and neurology teaching. Medical students from King's College London were invited to a virtual teaching session. We obtained preteaching and postteaching scores for students' subjective ability to recognize specific neurologic and neurosurgical emergencies, along with their confidence in the subject. Ninety-seven medical students attended the teaching session. For our sample group's subjective rating on their confidence in neurology or neurosurgery as a subject, we obtained a mean score of 3.87 and a median score of 4. Across all domains, there was a significant forward shift in the distribution curve of scores after teaching. We obtained statistically significant differences for all 9 neurologic and neurosurgical emergencies evaluated in our questionnaire (asymptotic significance <0.001). Median scores for all 9 conditions improved after the teaching session, with >50% positive ranks seen within each group. Across the teaching modalities compared, placement teaching was the highest scoring, whereas online lectures received a better rating than in-person lectures. In neurosurgery teaching, virtual seminars may compensate for deficiencies that exist within medical education, hence limiting the effects of neurophobia. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal conditions are the most common health condition seen in emergency departments. Hence, the most effective approaches to managing these conditions is of interest. This systematic review aimed to evaluate the effectiveness of allied health and nursing models of care for the management of musculoskeletal pain in ED. Methods: MEDLINE, EMBASE, CINAHL and LILACS databases were searched from inception to March 2023 for published randomised trials that compared the effectiveness of allied health and nursing models of care for musculoskeletal conditions in ED to usual ED care. Trials were eligible if they enrolled participants presenting to ED with a musculoskeletal condition including low back pain, neck pain, upper or lower limb pain and any soft tissue injury. Trials that included patients with serious pathology (e.g. malignancy, infection or cauda equina syndrome) were excluded. The primary outcome was patient-flow; other outcomes included pain intensity, disability, hospital admission and re-presentation rates, patient satisfaction, medication prescription and adverse events. Two reviewers performed search screening, data extraction, quality and certainty of evidence assessments. Results: We identified 1746 records and included 5 randomised trials (n = 1512 patients). Only one trial (n = 260) reported on patient-flow. The study provides very-low certainty evidence that a greater proportion of patients were seen within 20 min when seen by a physician (98%) than when seen by a nurse (86%) or physiotherapist (77%). There was no difference in pain intensity and disability between patients managed by ED physicians and those managed by physiotherapists. Evidence was limited regarding patient satisfaction, inpatient admission and ED re-presentation rates, medication prescription and adverse events. The certainty of evidence for secondary outcomes ranged from very-low to low, but generally did not suggest a benefit of one model over another. Conclusion: There is limited research to judge the effectiveness of allied health and nursing models of care for the management of musculoskeletal conditions in ED. Currently, it is unclear as to whether allied health and nurse practitioners are more effective than ED physicians at managing musculoskeletal conditions in ED. Further high-quality trials investigating the impact of models of care on service and health outcomes are needed. [ABSTRACT FROM AUTHOR]

The authors report the case of a 10-year-old child who was admitted to the emergency room with a penetrating lumbar spinal injury caused by an iron rod, which occurred accidentally during a recreational activity. The clinical presentation was a ponytail syndrome with paraparesis and cerebrospinal fluid discharge from the lumbar penetration point of the iron rod. The lumbar X-ray and computed tomography (CT) scan performed in the emergency room revealed the iron rod penetrating the spinal canal through the lamina of the L3 vertebra on the left, requiring urgent surgical management, consisting of laminectomy of L3 allowing the removal of the iron rod and repair of the dura mater without any damage to the roots of the cauda equina. The evolution was favorable with complete motor recovery at 3 months follow-up. [ABSTRACT FROM AUTHOR]

Background: Most posttraumatic syringomyelias occur in the cervical or thoracic spinal cord, where they contribute to myelopathic deficits. Here, a 40-year-old patient presented with the left leg monoparesis due to syringomyelia involving the conus medullaris 10 years after an L2 vertebral "crush" fracture. Case Description: Ten years following an L2 vertebral "crush" fracture, a 40-year-old male presented with the new onset of left lower leg paresis. The magnetic resonance imaging showed a T12-L1 syrinx associated with accompanying high-intensity areas above the syrinx located between the T11 and T12 levels. One month after placing a syringosubarachnoid (SS) shunt, both the syrinx and high-intensity area rapidly disappeared, and the left distal motor weakness resolved. Conclusion: Ten years following an L2 "crush" fracture, a 40-year-old male presented with the new onset of a cauda equina syndrome secondary to a posttraumatic T12-L1 syringomyelia causing expansion of the conus medullaris. [ABSTRACT FROM AUTHOR]

Background: Cauda equina syndrome (CES) is a consequence of a variety of etiologies. CES is most commonly due to compression of the thecal sac and nerve roots by a massive disc herniation. However, it rarely presents secondary to aortic occlusion. Aortoiliac occlusive disorder is usually associated with chronic claudication, erectile dysfunction, and diminished lower limb pulses. Acute aortic occlusion, however, is associated with serious complications such as spinal cord infarction and ischemia. It is also associated with a high risk of morbidity and mortality. Moreover, it poses a diagnostic challenge and may be overlooked. This report emphasizes the importance of considering vascular etiology as a differential diagnosis for CES. Case Description: This case report describes a unique case of aortic occlusion mimicking CES in a 56-year-old female patient. Conclusion: For patients presenting with cauda equina symptomatology, it is critical to consider vascular etiology, especially for those with cardiovascular risk factors. Spine surgeons and emergency physicians should maintain a high index of suspicion for vascular etiologies and consider appropriate imaging studies to promote early diagnosis and intervention to prevent subsequent neurological and life-threatening consequences. [ABSTRACT FROM AUTHOR]

Purpose: International guidelines for the management of patients with low back pain (LBP) are available, but there are no India‑specific guidelines for the diagnosis and management of LBP in primary care. This article aims to provide clinical insights for the diagnosis and treatment of LBP for primary care practitioners in India. Methods: A 3‑step modified Delphi method was used to get insights and opinions from a panel of 9 multidisciplinary specialist (neurology, orthopedics, and pain management). In rounds 1 and 2, 203 and 60 statements, respectively, were circulated to the expert panel and they were asked to respond with an “agree” or “disagree” to each statement and provide comments. At least 80% of the experts had to agree for a statement to reach a concordance. More than 80% concordance was reached for 175 and 32 statements in rounds 1 and 2, respectively. Round 3 was a direct interaction with the experts. Results: There was good agreement among the expert panelist in round 3 for the consensus‑derived statements from the earlier two rounds of the survey. The panel agreed that diagnostic triage is important to exclude specific spinal pathology, routine imaging is not recommended unless suspecting serious pathology, specialist referral is needed for serious pathologies/no improvement in pain with treatment, and management is to be individualized depending on etiology and patient factors. Conclusions: Primary care physicians are the first point of contact for patients with back pain. These consensus recommendations will assist primary care physicians in India to choose an appropriate course of action for managing patients with LBP. [ABSTRACT FROM AUTHOR]

Objective: To provide the most up-to-date recommendations on the role of surgery in first-time lumbar disk herniations (LDH) in order to standardize surgical management. Methods: We performed a literature search in PubMed, Scopus, and Embase from 2012 to 2022 using the following keywords: “lumbar disk herniation AND surgery”. Our initial search yielded 2610 results, which were narrowed down to 283 papers after standardized screening critera were applied. The data from these 283 papers were presented and discussed at two international meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee, where the Delphi method was employed and ten spine experts voted on five final consensus statements. Results: and Conclusions: The WFNS Spine Committee's guidelines cover four main topics: (1) role and timing of surgery in first-time LDH; (2) role of minimally invasive techniques in LDH; (3) extent of disk resection in LDH surgery; (4) role of lumbar fusion in the context of LDH. Surgery for LDH is recommended for failure of conservative treatment, cauda equina syndrome, and progressive neurological impairment, including severe motor deficits. In the latter cases, early surgery is associated with faster recovery and may improve patient outcomes. Minimally invasive techniques have short-term advantages over open procedures, but there is insufficient evidence to make a recommendation for or against the choice of a specific surgical procedure. Sequestrectomy and standard microdiscectomy demonstrated similar clinical results in terms of pain control, recurrence rate, functional outcome, and complications at short and medium-term follow-up. Lumbar fusion is not recommended as a routine treatment for first-time LDH, although it may be considered in specific patients affected by chronic axial pain or instability.

Introduction: Cauda equina syndrome (CES), conus medullaris syndrome (CMS), and sciatica-like syndromes or “sciatica mimics” (SM) may present as diagnostic and/or therapeutic dilemmas for the practicing spine surgeon. There is considerable controversy regarding the appropriate definition and diagnosis of these entities, as well as indications for and timing of surgery. Our goal is to formulate the most current, evidence-based recommendations for the definition, diagnosis, and management of CES, CMS, and SM syndromes. Methods: We performed a systematic literature search in PubMed from 2012 to 2022 using the keywords “cauda equina syndrome”, “conus medullaris syndrome”, “sciatica”, and “sciatica mimics”. Standardized screening criteria yielded a total of 43 manuscripts, whose data was summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Utilizing the Delphi method, we generated seven final consensus statements. Results and conclusion: s: We provide standardized definitions of cauda equina, cauda equina syndrome, conus medullaris, and conus medullaris syndrome. We advocate for the use of the Lavy et al classification system to categorize different types of CES, and recommend urgent MRI in all patients with suspected CES (CESS), considering the low sensitivity of clinical examination in excluding CES. Surgical decompression for CES and CMS is recommended within 48 h, preferably within less than 24 h. There is no data regarding the role of steroids in acute CES or CMS. The treating physician should be cognizant of a variety of other pathologies that may mimic sciatica, including piriformis syndrome, and how to manage these.

A 29-year-old man from Comoros presented with rapidly progressive paraplegia and sexual dysfunction. Magnetic resonance imaging (MRI) showed a contrast-enhanced conus medullaris lesion. Differential diagnoses included tumors, abscesses, and inflammatory diseases. Neurosurgery was delayed to complete examinations. Cerebral MRI showed three abscesses. Body computed tomography scan showed supracentimetric polyadenopathies, pulmonary nodules, prostatic lesion, and enhanced seminal vesicle, with hypermetabolism on positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose scan. Histology of lymph node biopsy showed granulomatous infiltration without acid-fast bacilli, and positive polymerase chain reaction for Mycobacterium tuberculosis. Lymph node culture was positive after 2 months, urine culture after 3 weeks, but cerebrospinal fluid and sputum cultures were negative. A 1-year antituberculosis therapy was initiated, associated with corticosteroids because the patient developed tuberculosis-immune reconstitution syndrome, revealed by the recurrence of neurological symptoms. After 2 months the patient completely recovered and could run. MRI showed stability of the voluminous tuberculoma with decrease of medullary edema. Avoiding surgery in those cases may prevent iatrogenic neurological deterioration. [ABSTRACT FROM AUTHOR]

This article discusses a case of a 64-year-old man who presented with back pain and cough. Imaging revealed masses in the chest and abdomen, as well as pleural effusions. Pathological examination of the tissue revealed a poorly differentiated malignant neoplasm that initially appeared to be anaplastic large-cell lymphoma (ALCL) based on immunohistochemical staining. However, further molecular testing confirmed a diagnosis of ALK-rearranged lung adenocarcinoma. The patient has responded to ALK-inhibitor therapy. The article emphasizes the importance of careful interpretation of immunohistochemical stains in cases of poorly differentiated ALK+/CD30+ neoplasms. [Extracted from the article]