an introduction

1. Conus Medullaris
&
Cauda Equina Syndrome
By: Ismah Haron
06/08/20141
‘Leg weakness is flaccid and areflexic
not spastic and hyperreflexic’

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Source: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006
Source:
Keith L. Moore and Anne Agur. Essential Clinical Anatomy, 3rd Edition

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Etiology
 Trauma
- Fracture, subluxation
- Penetrating trauma
 Herniated disc
- 90% at L4-L5 and L5-S1
 Spinal stenosis
- Developmental abnormality
- Degenerative disease
Picture from: Walter B. Greene. Netter's Orthopaedics 1st ed. 2006

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 Neoplasm
- Primary (schwannoma, paraganglioma)
- Metastatic (intracranial, lung, breast
and renal cell ca)
 Inflammations and infections
- Paget disease, epidural abscess
- Pyogenic and non pyogenic
Picture from: http://emedicine.medscape.com/

6.  Iatrogenic
- Misplaced pedicle screw, laminar hooks
- Continuous spinal anesthesia
06/08/20146Picture from: http://www.science-art.com

7. Conus medullaris syndrome Cauda equina syndrome
Vertebral level L1-L2 L2-sacrum
Spinal level Sacral cord segment and roots Lumbosacral nerve roots
Presentation Sudden and bilateral Gradual and unilateral
Radicular pain Less severe More severe
Low back pain More Less
Motor strength Symmetrical, less marked
hyperreflexic distal paresis of
LL, fasciculation
More marked asymmetric
areflexic paraplegia,
atrophy more common
Reflexes Ankle jerks affected Both knee and ankle jerks
affected
Sensory Localized numbness to perianal
area, symmetrical and bilateral
Localized numbness at
saddle area, asymmetrical,
unilateral
Sphincter
dysfunction
Early urinary and fecal
incontinence
Tend to present late
Impotence Frequent Less frequent
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Conus Medullaris vs. Cauda Equina Syndromes

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Illustration of saddle anesthesia;
- The S5, S4, and S3 nerves provide sensory
innervation to the rectum, perineum, and
inner thigh.
Source:
Journal of the American Academy of Orthopaedics Surgeons,
http://www.jaaos.org

9.  Radiology – MRI
 Laboratory – FBC, ESR
 Needle electromyography of the bilateral external
anal sphincter muscles
 Lumbar puncture
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Investigation

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Sagittal and axial CT scans of
thoracolumbar spine
demonstrating an L4 burst
fracture with retropulsion of
bone into the spinal canal
Source: Harrop, J. S., G. E. Hunt Jr, et al. (2004). "Conus medullaris and cauda
equina syndrome as a result of traumatic injuries: management principles."
Neurosurgical Focus 16(6): 1-23.

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Source: Harrop, J. S., G. E. Hunt Jr, et al. (2004). "Conus medullaris and cauda
equina syndrome as a result of traumatic injuries: management principles."
Neurosurgical Focus 16(6): 1-23.
MRI image shows
compression of the
distal lumbar and
sacral nerve rootles

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Sagittal MRI images
demonstrating large
central disc extrusion
at L5-S1 (arrows) with
compression on the
cauda equina.
Source: Levis, J. T. (2009). "Cauda
equina syndrome." Western Journal of
Emergency Medicine 10(1): 20.

13.  Discectomy - 1 2
 Laminectomy
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Method to Relieve Cord Compression

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Source: http://www.spinesurgeon.co.uk/media/lumbar-corpectomy.jpg
Corpectomy

15.  Important predictor of recovery
- The extent of perineal or saddle sensory deficit
 Patients with unilateral deficits have a better prognosis than
patients with bilateral deficits
 Females and patients with bowel dysfunction have been
reported to have worse outcomes postoperatively
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Prognosis
Source:
- Shaw A, Anwar H, Targett J, Lafferty K. Cauda equina syndrome versus saddle embolism. Ann R Coll Surg Engl. Sep 2008;90(6):W6-8.
- O'Laughlin SJ, Kokosinski E. Cauda equina syndrome in a pregnant woman referred to physical therapy for low back pain. J Orthop Sports Phys Ther.
Nov 2008;38(11):721.

16. THANK YOU
Other references:
- http://emedicine.medscape.com/article/1148690
- Oxford handbook of clinical medicine
- Oxford handbook of clinical surgery
- Apley’s consice system of orthopaedics and fractures 3rd edition
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