Sagittal T2WI showing a massive herniation at the L4-L5 level filling the spinal canal, compressing the dural sac, and abutting the posterior aspect of the spinal canal.
Cauda equina patients usually present with backache accompanied by bilateral radicular symptoms. Severe pain may suddenly appear and radiate bilaterally to the buttocks, thighs, or legs. Perineal numbness may develop. The phrase "Don't beat around the bush with numbness in the tush!" is apt. The most common early urological manifestation of cauda equina syndrome is inability to empty the bladder rather than incontinence. Urinary retention is frequently overlooked, because the patient does not complain of it in the first few hours.
Whenever this diagnosis is entertained the patient should be referred for an immediate neuroradiological evaluation.
MRI, the procedure of choice, or CT myelography will reveal a very large disc herniation compressing or totally obliterating the thecal sac (Figures 3-16 and 3-17). At times, the herniated disc is very large, fills the whole spinal canal, and may, superficially, resemble the thecal sac on axial CT images. Unlike a normal thecal sac it does not contain any neural elements within it; it pushes the thecal sac posteriorly. This finding is referred to as empty sac syndrome.
Prompt surgical decompression combined with removal of the herniated disc may preserve the cauda equina functions. Procrastination and delayed intervention may lead to permanent neurological deficits resulting in severe disability.
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Acquired spinal stenosis is very common in the elderly. It usually affects two spinal regions: the cervical and the lumbar. The basic underlying pathophysiological mechanisms leading to canal narrowing in the cervical and lumbar regions are the same. The resulting clinical manifestations, however, are quite different. The clinical symptoms depend on the degree of stenosis (how much space is left for the neural elements), the location of stenosis (central versus lateral stenosis), and the number of levels that are involved. Not uncommonly patients develop stenosis at both the cervical and the lumbar regions simultaneously.
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