DOCSLIB.ORG

Diseases of the Peripheral Nerves, Neuromuscular Junction, Or Uncertain Sites: Relevant Examination Techniques and Illustrative Video Segments

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Diseases of the Peripheral Nerves, Neuromuscular Junction, Or Uncertain Sites: Relevant Examination Techniques and Illustrative Video Segments IN-DEPTH: NEUROLOGY Diseases of the Peripheral Nerves, Neuromuscular Junction, or Uncertain Sites: Relevant Examination Techniques and Illustrative Video Segments Robert J. MacKay, BVSc (Dist), PhD, Diplomate ACVIM Author’s address: Alec P. and Louise H. Courtelis Equine Teaching Hospital, College of Veterinary Medicine, University of Florida, Gainesville, FL 32610; e-mail: mackayr@ufl.edu. © 2011 AAEP. 1. Introduction troversial issue. Peripheral nerve injuries are Mechanical injuries to peripheral nerves occur be- characterized by weakness of the innervated muscle cause of compression, entrapment, transection, lac- accompanied within 2 to 4 weeks by appreciable eration, ischemia, crushing, stretching, or chemical atrophy. When the injured nerve supplies impor- or burn damage.1,2 Neurapractic lesions are charac- tant extensor muscles of the limbs (e.g., as is the terized by a failure of conduction of the action po- case for radial, femoral, sciatic, and peroneal tential across the injured axonal segment.3 nerves), there is obvious alteration of gait. Areas of Axonotmesis is axonal interruption caused by axon cutaneous anesthesia occasionally accompany pe- and myelin sheath injury, whereas neurotmesis re- ripheral nerve injuries. Over the neck and trunk, flects complete disruption of endoneurium, perineu- cutaneous sensory innervation occurs in defined rium, and/or epineurium. Recovery by axonal bands associated with segmental dermatomes. regrowth is unlikely after neurotmesis.4 After ax- Damage to a peripheral spinal nerve or dorsal nerve onotmesis of motor nerves, muscle reinnervation is root results in cutaneous anesthesia/hypalgesia over to be expected and occurs by 2 separate mecha- the supplied dermatome. With damage to the pu- nisms: collateral sprouting and axonal regrowth.1 dendal nerve or its sacral nerve roots, there is anes- If there is incomplete loss of axons, reinnervation of thesia/hypalgesia of the perineal area. In contrast, muscle units by sprouting occurs in days to weeks. relatively small autonomous zones have been de- Reinnervation by axonal regrowth occurs at a rate of fined for sensory components of the ulnar, musculo- 1 millimeter per day (approximately 1 inch per cutaneous, median, femoral, tibial, and peroneal month). Skeletal muscle cells deprived of nerve nerves.5,6 Sympathetic fibers are distributed with supply ultimately undergo fibroblastic transforma- peripheral nerves, so denervated skin also may be tion; thus, reinnervation may not be possible after evident as circumscribed spontaneous sweating. more than 12 months, although this remains a con- The most common and important syndromes of me- NOTES AAEP PROCEEDINGS ր Vol. 57 ր 2011 363 IN-DEPTH: NEUROLOGY chanical injury to peripheral nerves of the limbs are mon and causes only transient toe-dragging. The described below.6–8 shoulder may be held in a flexed position and the elbow in an extended position. There is hypalgesia/ 2. Suprascapular Nerve anesthesia over the dorsomedial aspect of the knee The suprascapular nerve arises from C6 and C7 and proximal metacarpus and atrophy of the biceps spinal cord segments. Injury occurs most com- and brachialis muscles. monly when a horse’s shoulder is impacted at speed such that the nerve is injured as it curls around the 5. Median and Ulnar Nerves front of the neck of the scapula. There immediately The median nerve arises from C8 and T1 and the is laxity and lateral instability of the shoulder joint, ulnar nerve from T1 and T2. Injury to either can be which bows out or “pops” as the affected limb bears caused by injury to the brachial plexus or along the weight. Within 2 to 4 weeks of injury, there is medial aspect of the upper limb. Clinical findings obvious atrophy of the supraspinatus and infraspi- include a “tin soldier” gait, with decreased flexion natus muscles (Sweeney). At least 50% of such in- and dragging of the toe during protraction of the juries are predominantly neurapractic, and recovery limb and hypalgesia/analgesia of the skin of the of function (and muscle mass as there is atrophy) is caudal forearm, lateral metacarpus, and medial pas- evident within 30 days of injury and is complete tern areas and atrophy of the carpal and digital within 60 days. In more severe injuries with mor- flexors. bid axonal injury, successful reinnervation is evi- dent as recovery of muscle bulk in the ventral part of 6. Femoral Nerve the supraspinatus muscle beginning within 3 The femoral nerve arises from L3 to L5 and inner- months of injury. Maximal recovery takes an addi- vates muscles that flex the hip and extend the stifle. tional 3 to 12 months. Regrowth of the suprascap- The nerve can be damaged by ilial, femoral, or ver- ular nerve can be facilitated by surgery to resect tebral fractures. Ischemic injury is caused by pro- scar tissue and a constricting band (external neurol- longed stretch or increased tissue pressure during ysis) and reduce tension on the nerve as it crosses anesthesia in dorsal recumbency or after severe pro- the front of the scapula (often performed 3 to 6 longed dystocia.11 With unilateral paralysis, the months after injury). Removal of a piece of bone pelvic limb is abnormally flexed, usually with the from the neck of the scapula may further relax the foot flat on the ground, and buckles when the limb injured nerve, but the scapular notch created by this bears weight. In the case of bilateral involvement, procedure creates a potential nidus for scapular the horse is either unable to rise or stands uncom- fractures during recovery from anesthesia. fortably in a crouched position. If the nerve injury occurs proximal to the saphenous branch, there is 3. Radial Nerve anesthesia/hypalgesia of the skin over the medial The radial nerve innervates a flexor of the shoulder surface of the thigh and atrophy of the quadriceps and the extensors of the elbow, carpal, and digital muscle. joints. It arises from T1. The nerve root may be lacerated by fractures of the C7 or T1 vertebrae or 7. Sciatic Nerve first rib. The nerve is commonly damaged as a The sciatic nerve arises from L5-S1 and supplies result of humeral fracture9 and can be injured important extensors of the hip and flexors of the within the brachial plexus by trauma to the shoul- stifle. Damage usually is a result of deep injections der region. Ischemic damage may occur in horses into the caudal thigh.1 The nerve also may be in- anesthetized in lateral recumbency.10 The lower jured by fractures of the ilium or ischium or sacro- part of the nerve may be injured by dislocation or iliac or coxofemoral dislocations. The limb is held fractures that involve the elbow. slightly caudal with the dorsum of the hoof resting Horses with complete radial paralysis stand with on the ground. The stifle and hock are extended, the shoulder extended, the elbow “dropped,” and the whereas the distal joints are flexed. The leg is dorsum of the hoof resting on the ground. When dragged forward by the actions of the quadriceps forced to walk, the horse may partially protract the and biceps femoris muscles. These muscles, in con- limb by exaggerated extension of the shoulder; how- cert with the reciprocal apparatus, allow the horse ever, the toe drags and the horse collapses on the to bear some weight on the limb if the foot is first limb during the weight-bearing phase of the stride. placed in normal position. There is cutaneous hyp- If the site of damage is distal, the shoulder and algesia/anesthesia over most of the limb except for elbow are normal. Although the radial nerve has the medial thigh. numerous cutaneous sensory branches, injury to this nerve does not result in any consistent area of 8. Peroneal Nerve cutaneous anesthesia. The peroneal nerve arises from the sciatic trunk deep to the biceps femoris and is motor to the flexors 4. Musculocutaneous Nerve of the tarsus and the extensors of the digit. Paral- The musculocutaneous nerve arises from C7 and C8 ysis results in extension of the tarsus and flexion of and supplies flexors of the elbow. Injury is uncom- the distal joints of the pelvic limb. At rest, the limb 364 2011 ր Vol. 57 ր AAEP PROCEEDINGS IN-DEPTH: NEUROLOGY is held slightly caudally with the distal joints in sensation at each site by grasping a fold of skin flexed position and the dorsum of the hoof contacting between the jaws of the hemostat then firmly the ground. During walking, the limb is moved squeezing the skin and watching for evidence of a erratically. The toe is dragged along the ground conscious response by the horse. This is a behav- during the weak protraction phase, then is pulled ioral reaction and must be distinguished from a caudally as the horse attempts to bear weight. reflex that may occur without cognitive acknowl- There is atrophy of the cranial tibial and long and edgement. Sensory fields for some peripheral lateral digital extensors and immediate cutaneous nerves of horses have been described.6 hypalgesia/anesthesia over the lateral metatarsus. Test pelvic limb reflexes and function: First, as- sess extensor tone in the limb by testing resistance 9. Tibial Nerve to passive flexion. Next, perform the flexion test by The tibial nerve is the direct continuation of the pinching skin on the distal limb with a hemostat. sciatic nerve and innervates the gastrocnemius (ex- If there is no response, try pinching skin elsewhere tensor of the hock) and digital flexors. The limb is on the leg. A normal response is flexion of the limb, held flexed and the foot contacts the ground in nor- usually with some behavioral evidence that the mal position, the fetlock often partially collapses horse can feel the skin pinch.
Load more

Recommended publications
  • Positive Cases in Suspected Cauda Equina Syndrome
    Edinburgh Research Explorer The clinical features and outcome of scan-negative and scan- positive cases in suspected cauda equina syndrome Citation for published version: Hoeritzauer, I, Pronin, S, Carson, A, Statham, P, Demetriades, AK & Stone, J 2018, 'The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients', Journal of Neurology, vol. 265, no. 12. https://doi.org/10.1007/s00415- 018-9078-2 Digital Object Identifier (DOI): 10.1007/s00415-018-9078-2 Link: Link to publication record in Edinburgh Research Explorer Document Version: Publisher's PDF, also known as Version of record Published In: Journal of Neurology Publisher Rights Statement: This is an open access article distributed under the terms of the Creative Commons CC BY license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. General rights Copyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights. Take down policy The University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorer content complies with UK legislation. If you believe that the public display of this file breaches copyright please contact [email protected] providing details, and we will remove access to the work immediately and investigate your claim. Download date: 04. Oct. 2021 Journal of Neurology (2018) 265:2916–2926 https://doi.org/10.1007/s00415-018-9078-2 ORIGINAL COMMUNICATION The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients Ingrid Hoeritzauer1,2,5 · Savva Pronin1,5 · Alan Carson1,2,3 · Patrick Statham2,4,5 · Andreas K.
    [Show full text]
  • Cardiovascular Collapse Following Succinylcholine in a Paraplegic Patient
    ParajJleg£a (I973), II, 199-204 CARDIOVASCULAR COLLAPSE FOLLOWING SUCCINYLCHOLINE IN A PARAPLEGIC PATIENT By J. C. SNOW,! M.D., B. J. KRIPKE, M.D. , G. P. SESSIONS, M.D. and A. J. FINCK, M.D. University Hospital, Boston, DeKalb General Hospital, Decatur, Georgia, and Boston University School of Medicine, Boston, Massachusetts 02118 INTRODUCTION SEVERAL reports have been presented that have discussed cardiovascular collapse following the intravenous infusion of succinylcholine in patients with burns, massive trauma,tetanus, spinal cord injury, brain injury,upper or lower motor neuron disease,and uraemia with increased serum potassium. The purpose of this article is to report a spinal cord injured patient who developed cardiac arrest following administration of succinylcholine, possibly due to succinylcholine-induced hyperkalaemia. The anaesthesia management during the course of subsequent surgical procedure proved to be uneventful. CASE REPORT On 7 December 1971, a 20-year-old white man was admitted to the hospital after he fell 50 feet from a scaffold to the ground. He was reported to have been in good health until this accident. His legs and outstretched hands absorbed the major impact. No loss of consciousness was reported at any time. Neurologic examination revealed absent function of muscle groups in the distribution distal to L4, including the sacral segments. There were contractions of both quadriceps muscles in the adductors of the legs. The legs were held in flexion with no evidence of function in his hip abductors, extensors, knee flexors or anything below his knee. He had intact sensation over the entire thigh and medial calf. He had no apparent abdominal or cremasteric reflexes, no knee or ankle jerks, no Babinski responses, and no sacral sparing.
    [Show full text]
  • A Cauda Equina Syndrome in a Patient Treated with Oral Anticoagulants
    Paraplegia 32 (1994) 277-280 © 1994 International Medical Society of Paraplegia A cauda equina syndrome in a patient treated with oral anticoagulants. Case report l l l 2 l J Willems MD, A Anne MD, P Herregods MD, R Klaes MD, R Chappel MD 1 Department of Physical Medicine and Rehabilitation, 2 Department of Neurosurgery, A.z. Middelheim, Lindendreef 1, B-2020 Antwerp, Belgium. The authors report a patient who was on oral anticoagulants because of mitral valve disease and who developed paraplegia from subarachnoid bleeding involv­ ing the cauda equina. The differential diagnosis, investigations and treatment of the cauda equina syndrome are described. Keywords: cauda equina syndrome; anticoagulants; subarachnoid haemorrhage; mitral valve disease. Case report A 32 year old woman from Chile presented with a complete paraplegia. She claimed that the paraplegia had developed progressively over 8 months. Initially she had paraesthesiae in her feet, followed by progressive paresis of both legs, beginning distally, over a period of 3 months. Two months after the onset of illness she complained of bladder incontinence. There was no history of trauma or low back pain. Clinical examination in our hospital revealed a flaccid paraplegia at L1 level, and loss of sensation from the groins to the feet, including saddle anaesthesia. The knee and ankle jerks were absent. The anal sphincter was atonic. She had an indwelling urethral catheter, and she was faecally incontinent. Myelography and a CT scan were carried out, and a space-occupying lesion at the level of T12-L4 (Figs 1, 2) was defined. Surgical ex­ ploration was done to determine the cause.
    [Show full text]
  • On Lumbar Disc Herniation – Aspects of Outcome After Surgical Treatment
    From the Dept. of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet and the Dept. of Clinical Science and Education, Södersjukhuset, Karolinska Institutet Stockholm Sweden On Lumbar Disc Herniation – Aspects of outcome after surgical treatment Peter Elkan Stockholm 2017 1 The frontpage picture is published with license from: Zephyr/Science Photo Library/IBL http://www.sciencephoto.com/ All previously published papers were reproduced with permission from the publisher. Published by Karolinska Institutet. Printed by E-PRINT © Peter Elkan, 2017 ISBN 978-91-7676-712-2 2 Institutionen för klinisk vetenskap, intervention och teknik, Enheten för ortopedi och bioteknologi, Karolinska Institutet On Lumbar Disc Herniation – Aspects of outcome after surgical treatment AKADEMISK AVHANDLING som för avläggande av medicine doktorsexamen vid Karolinska Institutet offentligen försvaras i Aulan, 6 tr, Södersjukhuset Sjukhusbacken 10, Stockholm Fredag 19 maj, kl 09:00 Av Peter Elkan Handledare Opponent Docent Paul Gerdhem Enheten för ortopedi Docent Bengt Sandén Institutionen för och bioteknologi Institutionen för klinisk kirurgiska vetenskaper vetenskap, intervention och teknik Uppsala Universitet Karolinska Institutet Bihandledare Betygsnämnd Professor Sari Ponzer Institutionen för klinisk Professor Olle Svensson Institutionen för forskning och utbildning, Södersjukhuset kirurgi och perioperativ vetenskap Karolinska institutet Umeå Universitet Med dr Ulric Willers Institutionen för klinisk Professor Lars Weidenhielm Institutionen för forskning och utbildning, Södersjukhuset molekylär medicin och kirurgi Karolinska institutet Karolinska Institutet Adj. professor Rune Hedlund Institutionen för Docent Gunnar Ordeberg Institutionen för kliniska vetenskaper kirurgiska vetenskaper Sahlgrenska Akademin Uppsala Universitet Stockholm 2017 3 4 To my dear family, all patients suffering from sciatic pain and all patients who have contributed with data in this project.
    [Show full text]
  • Non-Traumatic Rupture of the Ligamentum Flavum With
    Interdisciplinary Neurosurgery 16 (2019) 51–53 Contents lists available at ScienceDirect Interdisciplinary Neurosurgery journal homepage: www.elsevier.com/locate/inat Case Reports & Case Series Non-traumatic rupture of the ligamentum flavum with symptomatic ☆ spontaneous lumbar epidural hematoma: A case report T ⁎ Ashwin G. Ramayya (MD, PhD)a, ,1, Alejandro Carrasquilla (BS)c,1, Frederick L. Hitti (MD, PhD)a, Peter J. Madsen (MD)a, Jayesh P. Thawani (MD)a, Kimberly Imbesi (MD)b, Michael Trotter (MD)b, David K. Kung (MD)a, James Schuster (MD, PhD)a a Department of Neurosurgery, The University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19103, United States b Department of Emergency Medicine, The University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19103, United States c Perelman School of Medicine, The University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19103, United States ARTICLE INFO ABSTRACT Keywords: We present a case of a healthy 31 year-old male plumber who presented to the emergency room with acute onset Ligamentum flavum rupture back pain that acutely developed after simply bending over. He developed radiculopathy and cauda equina Epidural hematoma syndrome over a period of hours. An MRI demonstrated an acute lumbar epidural hematoma and a disruption of Cauda equina syndrome the ligamentum flavum, suggesting that he may have torn the ligament with lumbar flexion. The patient was Back pain taken to the operating room for an emergent lumbar decompression and recovered full neurological function post-operatively. To our knowledge, this is the first report of a spontaneous symptomatic lumbar epidural he- matoma resulting from a non-traumatic ligamentum flavum rupture.
    [Show full text]
  • Extraordinary Recovery from Complete Cauda Equina Syndrome Following L3 Fracture
    Citation: Spinal Cord Series and Cases (2016) 2, 16027; doi:10.1038/scsandc.2016.27 © 2016 International Spinal Cord Society All rights reserved 2058-6124/16 www.nature.com/scsandc CASE REPORT Against the odds: extraordinary recovery from complete cauda equina syndrome following L3 fracture. Time still matters Silvia Antiga1, Klint Asafu-Adjaye1, Fahim Anwar1 and Pierluigi Vergara2 INTRODUCTION: Cauda equina syndrome secondary to lumbar fracture is a relative rare event. Although it is usually considered as an emergency, there is still controversy in the literature regarding the optimal timeframe of surgical intervention in complete spinal cord and cauda equina injuries. CASE PRESENTATION: We report a case of a 24-year-old victim of a road traffic accident admitted with an L3 fracture causing complete cauda equina syndrome, who underwent early surgery within 12 h and made an extraordinary recovery (from AIS A to E). DISCUSSION: Although the timing of surgery in complete traumatic spinal cord injury and cauda equina syndrome remains controversial, this case highlights the importance of early surgical intervention even in complete injuries. Spinal Cord Series and Cases (2016) 2, 16027; doi:10.1038/scsandc.2016.27; published online 10 November 2016 INTRODUCTION endplate fracture of the third lumbar vertebra (AOspine type A3), Cauda equina syndrome (CES) is a severe neurological disorder with a retropulsed fragment lying within the spinal canal and resulting from an injury to the cauda equina and causing causing 490% stenosis (Figure 1). polyradicular symptomatology, including lower limbs and sphincter The patient developed some paraesthesia in both lower limbs deficits. CES not only affects the physical well-being of the individual, ~ 8 h following injury, but with persistent numbness and no but can also have psychological consequences that may have long- improvement in motor, bladder or bowel function.
    [Show full text]
  • Chronic Renal Failure in Equine Due to Ascending Pyelonephritis Predisposed by Cauda Equina Syndrome: Case Report
    Arq. Bras. Med. Vet. Zootec., v.70, n.2, p.347-352, 2018 Chronic renal failure in equine due to ascending pyelonephritis predisposed by cauda equina syndrome: Case report [Insuficiência renal crônica em equino devido à pielonefrite ascendente predisposta por síndrome da cauda equina: Relato de caso] J.H. Fonteque1, M.C.S. Granella2*, A.F. Souza², R.P. Mendes², J. Schade3, V. Borelli1, A. Costa3, P.G. Costa4 1Universidade do Estado de Santa Catarina ˗ Lages, SC 2Aluno de graduação - Universidade do Estado de Santa Catarina ˗ Lages, SC 3Aluno de pós-graduação ˗ Universidade do Estado de Santa Catarina ˗ Lages, SC 4Médica veterinária autônoma ˗ Curitibanos, SC ABSTRACT This report describes the case of a mare, of the Campeiro breed, used as an embryo donor, which had recurrent cystitis and urinary incontinence crisis. Clinical signs evolved to progressive weight loss, anorexia, apathy, and isolation from the group. Physical examination showed tail hypotonia, perineal hypalgesia, rectal and bladder sagging compatible with signs related to cauda equina syndrome. Complementary laboratory and sonographic assessment, and necropsy confirmed the diagnosis of chronic renal failure (CRF), which was attributed to the ascending pyelonephritis. The examination of urine culture showed growth of bacteria of the genus Streptococcus sp. This is a rare case in the equine species where the lower motor neuron dysfunction led the development of infectious process in the urinary tract, progressing to renal chronic condition incompatible with life. Keywords: Campeiro, nephropathy, neuropathy, urinary tract. RESUMO Descreve-se o caso de uma égua, da raça Campeiro, utilizada como doadora de embriões, que apresentava quadros de cistite recorrente e incontinência urinária.
    [Show full text]
  • Cauda Equina Syndrome and Other Emergencies
    Cauda equina syndrome and other emergencies Mr ND Mendoza Mr JT Laban Charing Cross Hospital Definition • A neurosurgical spinal emergency is any lesion where a delay or injudicious treatment may leave…… • The patient • The surgeon • and the barristers Causes of acute spinal cord and cauda equina compression • Degenerative • Infection – Lx / Cx / Tx disc prolapse – Vertebral body – Cx / Lx Canal stenosis –Discitis – Osteoporotic fracture – Extradural abscess • Trauma •Tumour – Instability – Metastatic – Penetrating trauma – Primary –Haematoma •Vascular – Iatrogenic e.g Surgiceloma – Spinal DAVF • Developmental – Syrinx / Chiari malformation CaudaEquinaSyndrome Kostuik JP. Controversies in cauda equina syndrome. Current Opin Orthopaed. 1993; 4 ; 125 - 8 Lumbar disc prolapse William Mixter Cauda Equina Syndrome : Clinical presentation • Bilateral sciatica • Saddle anaesthesia • Sphincter disturbance – urinary retention: check post-void residual • 90% sensitive ( but not specific ) • Very rare for pt without retention to have cauda equina – urinary / faecal incontinence – anal sphincter tone may be reduced in 60 - 80% pts • Motor weakness / Sensory loss • Bilateral loss of ankle jerk Investigations Radiological Plain X-rays X MRI CT Myelography You’ll be lucky ! Central disc prolapse 35 yr female acute cauda equina syndrome Lumbar Canal Stenosis 50 yr female with acute on chronic cauda equina syndrome Congenital narrow canal + PID Management • Decompression – Lx Laminectomy – Hemilaminectomy – Microdiscectomy • Complications – Incomplete decomp. –CSF leak Outcome and relationship to time of onset to surgery Cauda equina syndrome secondary to lumbar disc herniation : a meta-analysis of surgical outcomes. Ahn UM et al . Spine 2000 : 25; 1515 – 1522 ‘ a significant advantage to treating patients within 48 hrs versus more than 48 hours after the onset of CES’ Loss of bladder function is associated with poor prognosis Outcome and relationship to time of onset to surgery Cauda equina syndrome: the timing of surgery probably does influence outcome Todd N.V.
    [Show full text]
  • Non-Surgical Treatment for Cauda Equina Syndrome After Lumbar Epidural Block
    ISSN 2466-0167 Asian J Pain 2017;3(2):36-38 CASE REPORT AJP Non-surgical Treatment for Cauda Equina Syndrome after Lumbar Epidural Block Jin-Woo Park, Junseok W Hur, Jang-Bo Lee, Jung-Yul Park Department of Neurosurgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea Lumbar epidural block is an important modality to manage degenerative spinal disease. Although the procedure related complication rate is low, cauda equina syndrome after epidural block rarely occurs. Herein we discuss a case of block related cauda equina syndrome without any thecal sac compressive lesion. A 50 years old woman have been suffered from bilateral buttock pain and claudication. She was diagnosed as L4/5 spinal stenosis and L5/S1 herniation of intervertebral disc(HIVD). Lumbar epidural block has been performed from other clinic, however, neurologic deterioration developed subsequently; bilateral lower extremities par- esthesia/weakness (G4), perineal numbness, and urinary incontinence. After transfer to our institute, we conducted magnetic reso- nance image (MRI) and confirmed there was no neural compressive lesion. After 3 days conservative treatments, perineal numbness gradually improved but paresthesia and both leg weakness remained. After one week, selective nerve root block (SNRB) was per- formed carefully and the patient showed improvement of symptoms by about 70%. Second SNRB was performed one week after first SNRB. After the second SNRB, the symptom improved enough to withstand. The patient still complained of mild bilateral both leg pain after discharge. Two months later, the patient underwent radiofrequency rhizotomy and the symptoms fully recovered. In case of cauda equina subsequent to block without any thecal sac compressive lesion, could be treated with non-operative modalities.
    [Show full text]
  • Postlumbar Puncture Arachnoiditis Mimicking Epidural Abscess Mehmet Sabri Gürbüz,1 Barıs Erdoğan,2 Mehmet Onur Yüksel,2 Hakan Somay2
    Learning from errors CASE REPORT Postlumbar puncture arachnoiditis mimicking epidural abscess Mehmet Sabri Gürbüz,1 Barıs Erdoğan,2 Mehmet Onur Yüksel,2 Hakan Somay2 1Department of Neurosurgery, SUMMARY and had increased gradually before the patient was ğ ı ğ ı A r Public Hospital, A r , Lumbar spinal arachnoiditis occurring after diagnostic referred to us. On our examination, the body tem- Turkey 2Department of Neurosurgery, lumbar puncture is a very rare condition. Arachnoiditis perature was 38.5°C. There was no neurological Haydarpasa Numune Training may also present with fever and elevated infection deficit but a slight tenderness in the low back. The and Research Hospital, markers and may mimic epidural abscess, which is one examination of the other systems was unremarkable. Istanbul, Turkey of the well known infectious complications of lumbar puncture. We report the case of a 56-year-old man with Correspondence to INVESTIGATIONS Dr Mehmet Sabri Gürbüz, lumbar spinal arachnoiditis occurring after diagnostic Laboratory examination revealed elevated erythro- [email protected] lumbar puncture who was operated on under a cyte sedimentation rate (80 mm/h) and C reactive misdiagnosis of epidural abscess. In the intraoperative protein level (23 mg/L) with 9.5×109/L white blood and postoperative microbiological and histopathological cells. Preoperative blood culture for Mycobacterium examination, no epidural abscess was detected. To our and other microorganisms and sputum culture for knowledge, this is the first case of a patient with Mycobacterium were all negative. Non-contrast- postlumbar puncture arachnoiditis operated on under a enhanced T1-weighted sagittal MRI of the patient misdiagnosis of epidural abscess reported in the demonstrated a nearly biconcave lesion resembling literature.
    [Show full text]
  • Definitions of Traumatic Conus Medullaris and Cauda
    Spinal Cord (2017) 55, 886–890 & 2017 International Spinal Cord Society All rights reserved 1362-4393/17 www.nature.com/sc ORIGINAL ARTICLE Definitions of traumatic conus medullaris and cauda equina syndrome: a systematic literature review E Brouwers1, H van de Meent2, A Curt3, B Starremans4, A Hosman5 and R Bartels1 Study design: A systematic review. Objectives: Conus medullaris syndrome (CMS) and cauda equina syndrome (CES) are well-known neurological entities. It is assumed that these syndromes are different regarding neurological and functional prognosis. However, literature concerning spinal trauma is ambiguous about the exact definition of the syndromes. Methods: A MEDLINE, EMBASE and Cochrane literature search was performed. We included original articles in which clinical descriptions of CMS and/or CES were mentioned in patients following trauma to the thoracolumbar spine. Results: Out of the 1046 articles, we identified 14 original articles concerning patients with a traumatic CMS and/or CES. Based on this review and anatomical data from cadaveric and radiological studies, CMS and CES could be more precisely defined. Conclusion: CMS may result from injury of vertebrae Th12–L2, and it involves damage to neural structures from spinal cord segment Th12 to nerve root S5. CES may result from an injury of vertebrae L3–L5, and it involves damage to nerve roots L3–S5. This differentiation between CMS and CES is necessary to examine the hypothesis that CES patients tend to have a better functional outcome. Spinal Cord (2017) 55, 886–890; doi:10.1038/sc.2017.54; published online 23 May 2017 INTRODUCTION described clinical symptoms that were caused by compression of the Traumatic injuries of the thoracolumbar spine can result in conus CE and named this as ‘cauda equina compression syndrome’.20 From medullaris syndrome (CMS) or cauda equina syndrome (CES).
    [Show full text]
  • Cauda Equina Syndrome | the BMJ 23/11/2019, 1215
    Cauda equina syndrome | The BMJ 23/11/2019, 1215 Intended for healthcare professionals Clinical Review Cauda equina syndrome BMJ 2009; 338 doi: https://doi-org.sheffield.idm.oclc.org/10.1136/bmj.b936 (Published 31 March 2009) Cite this as: BMJ 2009;338:b936 Chris Lavy, honorary professor and consultant orthopaedic surgeon, Andrew James, specialist registrar, James Wilson-MacDonald, consultant spine surgeon, Jeremy Fairbank, professor of spine surgery 1 Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford OX3 7LD Correspondence to: C Lavy [email protected] Summary points Cauda equina syndrome is rare, but devastating if symptoms persist Clinical diagnosis is not easy and even in experienced hands is associated with a 43% false positive rate The investigation of choice is magnetic resonance imaging Once urinary retention has occurred the prognosis is worse Good retrospective evidence supports urgent surgery especially in early cases Litigation is common when the patient has residual symptoms An understanding of cauda equina syndrome is important not only to orthopaedic surgeons and neurosurgeons but also to general practitioners, emergency department staff, and other specialists to whom these patients present. Recognition of the syndrome by all groups of clinicians is often delayed as it presents with bladder, bowel, and sexual problems, which are common complaints and have a variety of causes. Patients may not mention such symptoms because of embarrassment or because the onset is slow and insidious. Cauda
    [Show full text]