Figure 317

Dorn Spinal Therapy

Spine Healing Therapy

Get Instant Access

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.

Clinical Presentation

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.

Imaging Studies

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.

Management

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.

Bibliography

Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, KostuikJP: Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine 25: 1515-1522, 2000.

Anderson DG, Albert TJ, Fraser JK, Risbud M, Wuisman P, Meisel HJ, Tannoury C, Shapiro I, Vaccaro AR: Cellular therapy for disc degeneration. Spine 30 (17 Suppl): S14-S19, 2005.

Boden SD: The use of radiographic imaging studies in the evaluation of patients who have degenerative disorders of the lumbar spine. J Bone Joint Surg Am 78: 114-124, 1996.

Brain WR, Northfield D, Wilkinson M: The neurological manifestations of cervical spondylosis. Brain 75: 187-225, 1952.

Brodke DS, Ritter SM: Nonoperative management of low back pain and lumbar disc degeneration. J Bone Joint Surg Am 86: 1810-1818, 2004.

Buirski G, Silberstein M: The symptomatic lumbar disc in patients with low back pain: Magnetic resonance imaging appearances in both a symptomatic and control population. Spine 18: 1808-1811, 1993.

Buttermann GR: Treatment of lumbar disc herniation: Epidural steroid injection compared with discectomy. J Bone Joint Surg Am 86: 670-679, 2004.

Carragee EJ, Kim DH: A prospective analysis of magnetic resonance imaging findings in patients with sciatica and lumbar disc herniation. Correlation of outcomes with disc fragment and canal morphology. Spine 22: 1650-1660, 1997.

Carragee EJ, Paragioudakis SJ, Khurana S: 2000 Volvo award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems. Spine 25: 29872992, 2000.

Cassinelli EH, Hall RA, Kang JD: Biochemistry of intervertebral disc degeneration and the potential for gene therapy applications. Spine J 1: 205-214, 2001.

Cooke PM, Lutz GE: Internal disc disruption and axial back pain in the athlete. Phys Med Reha-bil Clin N Am 11: 837-865, 2000.

Debois V, Herz R, Berghmans D, Hermans B, Herregodts P: Soft cervical disc herniation. Influence of cervical spinal canal measurements on development of neurologic symptoms. Spine 24: 1996-2002, 1999.

Diaz JH: Permanent paraparesis and cauda equina syndrome after epidural blood patch for postural puncture headache. Anesthesiology 96: 1515-1517, 2002.

Ernst CW, Stadnik TW, Peeters CB, Osteaux MJC: Prevalence of annular tears and disc herniations on MR images of the cervical spine in symptom free volunteers. Eur J Radiol 55: 409-414, 2005.

Goupille P, Jayson MI, Valat JP, Freemont AJ: The role of inflammation in disk herniation-associated radiculopathy. Semin Arthritis Rheum 28: 60-71, 1998.

Hehng Y, Liew SM, Simmons ED: Value of magnetic resonance imaging and discography in determining the level of cervical discectomy and fusion. Spine 29: 2140-2145, 2004.

Inufusa A, An HS, Lim TH, Hasegawa T, Haughton VM, Nowicki BH: Anatomic changes of the spinal canal and intervertebral foramen associated with flexion-extension movement. Spine 21: 2412-2420, 1996.

Ito T, Takano Y, Nobuhiro Y Types of lumbar herniated disc and clinical course. Spine 26: 648651, 2001.

Jackson RP, Glah JJ: Foraminal and extraforaminal lumbar disc herniation: Diagnosis and treatment. Spine 12: 577-585, 1987.

Jones A, Clarke A, Freeman BJC, Lam KS, Grevitt MP: The Modic classification. Inter- and intraobserver error in clinical practice. Spine 30: 1867-1869, 2005.

Kankaanpaa M, Taimela S, Airaksinen O, Hanninen O: The efficacy of active rehabilitation in chronic low back pain. Effect of pain intensity, self-experienced disability, and lumbar fatigability. Spine 24: 1034-1042, 1999.

Lejeune JP, Hladky JP, Cotton A, Vinchon M, Christiaens JL: Foraminal lumbar disc herniation. Experience with 83 patients. Spine 19: 1905-1908, 1994.

Levicoff EA, Gilbertson LG, Kang JD: Gene therapy to prevent or treat disc degeneration: Is this the future? SpineLine March/April: 10-16, 2005.

Mehta TA, Sharp DJ: Acute cauda equina syndrome caused by a gas-containing prolapsed intervertebral disk. J Spinal Disord 13: 532-534, 2000.

Mitchell MJ, Sartoris DJ, Moody D, Resnick D: Cauda equina syndrome complicating ankylosing spondylitis. Radiology 175: 521-525, 1990.

Modic MT, Steinberg PM, Ross JS, Massaryk TJ, Carter JR: Degenerative disk disease: Assessment of changes in vertebral body marrow with MR imaging. Radiology 166: 193-199, 1988.

Ohmori K, Kanamori M, Kawaguchi Y, Ishihara H: Clinical features of extraforaminal lumbar disc herniation based on the radiographic location of the dorsal root ganglion. Spine 26: 662666, 2001.

Olmarker K, Rydevik B: Pathophysiology of sciatica. Orthop Clin N Am 22: 223-234, 1991.

O'Neill C, Alamin T, Weinstein SM: The utility of provocation discography in the evaluation and treatment of chronic low back pain: A state of the art debate. SpineLine March/April: 17-25, 2005.

Peng B, Wu W, Hou S, Li P, Zhang C, Yang Y: The pathogenesis of discogenic low back pain. J Bone Joint Surg Br 87: 62-67, 2005.

Prasad SS, O'Malley M, Caplan M, Shackleford IM, Pydisetty RK: MRI measurements of the cervical spine and their correlation to Pavlov's ratio. Spine 28: 1263-1268, 2003.

Rao R: Neck pain, cervical radiculopathy, and cervical myelopathy. Pathophysiology, natural history and clinical evaluation. J Bone Joint Surg Am 84: 1872-1881, 2002.

Rhode RS, Kang JD: Thoracic disc herniation presenting with chronic nausea and abdominal pain. A case report. J Bone Joint Surg Am 86: 379-381, 2004.

Rydevik B, Brown MD, Lundborg G: Pathoanatomy and pathophysiology of nerve root compression. Spine 9: 7-15, 1984.

Shapiro S: Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine 25: 348-351, 2000.

Slipman CW, Lipetz JS, Jackson HB, Rogers DP, Vresilovic EJ: Therapeutic selective nerve root block in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain: A retrospective analysis with independent clinical review. Arch Phys Med Rehabil 81: 741-746, 2000.

Tsitouridis I, Sayegh FE, Papapostolou P, Chondroamtidou S, Goustsaridou F, Emmanouilidou M, Sidiropoulou MS, Kapetanos GA: Disc-like herniation in association with gas collection in the spinal canal: CT evaluation. Eur J Radiol 56: 1-4, 2005.

Uhlenbrock D, Henkes H, Weber W, Felber S, Kuehne D: Degenerative disorders of the spine, pp. 159-268 in Uhlenbroch D: MR imaging of the spine and spinal cord. Georg Thieme Verlag, 2004.

Wood KB, Blair JM, Aepple DM, Schendel MJ, Garvey TA, Gundry CR, Heitoff KB: The natural history of asymptomatic thoracic disc herniations. Spine 22: 525-530, 1997.

Wong AK, Leong CP, Chen CM: The traction angle and cervical intervertebral separation. Spine 17: 136-138, 1992.

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.

Was this article helpful?

0 0

Post a comment