Sacral sparing with cauda equina compression from central lumbar intervertebral disc prolapse.

Abstract

SUMMARY Sparing of sensation in sacral dermatomes and of sphincter control was found in eight out of fourteen cases of severe cauda equina compression from massive central lumbar disc prolapse. Although the triangular shape of the lumbar spinal canal may be one factor for this it was found from a necropsy model that the increase in linear strain on the stretched roots of the cauda equina is least in the more centrally placed lower sacral roots. It is argued that the lower tension in these roots is determined by Young's Modulus.It is well known in cases of spinal cord compression from intrinsic or extrinsic tumours, cutaneous sensibility may be preserved in the sacral dermatomes when it has been lost or impaired in the lumbar and thoracic territory below the segmental level of the lesion. This phenomenon has been ascribed to lamination of the dermatomes within the spinal cord, so that the sacral spinal pathways may be the least compressed, particularly from extrinsic lesions. The fact that the same phenomenon combined with sphincter preservation may occur with a large central lumbar disc prolapse causing cauda equina compression has passed largely unobserved. No reference to this feature could be found in the English or American literature, though some authors noted that the sensory loss was asymmetrical, incomplete or even absent.' 2 Paillas and his colleagues did observe sparing of sensation in sacral dermatomes in two out of six cases of severe cauda equina syndrome due to central lumbar disc prolapse, and believed that the explanation was the triangular shape of the lumbar spinal canal; they believed that the more centrally situated sacral nerves would be less compromised than the more laterally placed lumbar roots.3 (fig 1). A personally studied case prompted the further investigation of the phenomenon. Case report A male, aged 42 years had six years previously suffered an episode of severe low back pain after heavy lifting which lasted several weeks; recovery was complete. Two weeks before his transfer from another hospital, he again lifted a very heavy object, and experienced excruciating back pain spreading to the front of both legs, and then he gradually lost the power in his lower limbs, so that after ten days he was unable to walk or stand; the front of his thighs, and of his legs below the knees felt numb. There was no difficulty in holding or passing urine although he was constipated. It was not possible to examine him standing because of pain and weakness. Straight leg raising was very limited and the femoral stretch test strongly positive. At the hips, the power was about MRC 4, both for flexion and extension; at the knees, for extension it was MRC 3 and flexion MRC 4; ankle and toe movements were between MRC 3 and 2.There was gross blunting to pin prick in the front of the thighs below the second lumbar dermatome which extended down over the shins and lateral borders of the calves to the dorsum and outer borders of the feet. However, in the soles of the feet and the back of the calves, back of the...

Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life

“…3,4,12,14,17,[21][22][23]30,[32][33][34][35][36][37][38][39] A recent meta-analysis 4 demonstrated improved outcomes when CES patients were treated within 48 hours, but this meta-analysis included only observational studies, thereby limiting the strength of its conclusions. 40,41 Using animal models of CES, Sayegh and colleagues 2 found no differences in neurologic outcomes with early versus delayed intervention, but better recovery times for somatosensory evoked potentials (SEP).…”

Complaints of micturition, defecation and sexual function in cauda equina syndrome due to lumbar disk herniation: a systematic review

“…One study was reported in two publications [19,20]. Reasons to exclude articles were among others small patient numbers [28,29], inclusion of HNP patients instead of CES patients exclusively [30][31][32][33][34][35][36][37], inclusion of hemi CES instead of total CES [38], no imaging done [3,4,[39][40][41], no evaluation of a primary treatment [42][43][44], follow-up of at least 2 weeks not guaranteed [45][46][47][48][49] and no adequate report on post-operative functions [50].…”

Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies

“…A number of studies did not meet our inclusion criteria, even though some of them have been cited quite regularly in the CES literature (Table 1). 3,5,6,15,16,19,23,27,41,42,44,[46][47][48][49][50]52,57,59,64,65,72,79,80,87,101,[103][104][105][106]115,123,133,138,144,151,164,166,178 We could only accept 10 of the 42 studies upon which Ahn et al 2 relied. 7,30,58,67,87,90,94,122,168,170 We eliminated earlier studies that appeare...…”