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Introduction: Elsberg syndrome is an uncommon cause of lumbosacral radiculitis that presents as a constellation of symptoms, including urinary retention, bowel incontinence, severe constipation, impotence, and saddle anesthesia., Case Presentation: A 32-year-old female presented to the emergency department with complaints of bilateral leg pain and urinary retention. Two weeks prior, she noticed new genital lesions and had a positive nucleic acid amplification test for herpes simplex virus (HSV) type 2. Magnetic resonance imaging of the lumbar spine showed extraforaminal enhancement and edema-like signal within all the lumbosacral nerve roots. Cerebrospinal fluid (CSF) studies, CSF culture, and meningitis panel were unremarkable., Discussion: Elsberg syndrome likely accounts for 5% to 15% of patients with cauda equina syndrome. However, physicians often leave out Elsberg syndrome in the differential diagnosis of acute cauda equina syndrome and do not perform HSV testing to facilitate definitive diagnosis. As a result, Elsberg syndrome is underreported., Conclusions: A high degree of clinical suspicion should be deployed when diagnosing patients with bilateral lumbosacral radiculitis, as early detection and treatment of Elsberg syndrome prevents long-term morbidity., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

BACKGROUND Aside from the rarity of mobile spinal schwannomas, the coexistence of these tumors with herniated intervertebral disc is also scarce. Furthermore, cauda equina syndrome (CES), as a manifestation of intraspinal schwannomas has been reported rarely. Described here is a case of simultaneous lumbar disc bulge and mobile spinal schwannoma presented with intermittent symptoms of CES. CASE REPORT A 62-year-old man presented with severe but intermittent leg pain for 2 weeks, which later progressed to an episode of lower extremity weakness and difficulty in urination. Magnetic resonance imaging revealed an intraspinal tumor that moved in position relative to the L1-2 disc bulge on scans 6 h apart, with associated spontaneous regression in symptoms. The tumor was found to be a mobile spinal schwannoma, originated from a nerve root. A standard microdissection technique was used to remove the tumor through a spinous process-sparing unilateral approach, with complete laminectomy of L1. Use of intraoperative ultrasound facilitated the accurate tumor localization. Postoperatively, the patient no longer had symptoms. CONCLUSIONS This report presents a combination of a common spinal pathology, intervertebral disc herniation, alongside a rare condition, mobile spinal schwannoma, whose uncommon clinical manifestations, such as CES can cause irreversible neurological deficits. Surgeons need to remain vigilant of potential atypical scenarios when treating patients. Surgical treatment challenges regarding the mobility of tumors, such as accurate localization, should be addressed using intraoperative imaging to avoid wrong-level surgery. To mitigate the irreversible neurological complications, patients should receive comprehensive information for alarming signs of CES.

Background: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period., Methods: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES., Results: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up., Conclusions: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation., Competing Interests: Robert J. Trager acknowledges that he has received royalties as the author of two texts on the topic of sciatica. The authors have declared no competing interests., (Copyright: © 2024 Trager et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Secondary central nervous system lymphoma (SCNSL) is a known complication of immunocompromised patients with most cases involving the brain parenchyma. Reports of cauda equina syndrome (CES) caused by SCNSL are exceedingly scarce as involvement of this anatomical region is extremely uncommon., Case Presentation: We report a case of a 46-years-old, African, female patient with human immunodeficiency virus (HIV) who developed CES in the context of SCNSL. There were no blasts present in the peripheral blood smear. We provide a review of the literature, discussion of the clinical evolution of this patient and the radiological/histopathological findings. The patient ultimately responded well to induction chemotherapy and high dose methotrexate., Conclusion: This case report demonstrates that CES, while a rare occurrence in this clinical context, should be considered in at-risk patients especially those presenting with abnormal neurological findings. Prompt recognition may prevent permanent neurological injury and obviate the need for more invasive therapeutic interventions., (© 2023. The Author(s).)

Background: Cauda Equina Syndrome (CES) after Combined Spinal-Epidural Anesthesia (CSEA) is a rare disease that most of the time need surgery to relieve spinal cord compression., Case Presentation: A 34-year-old male patient underwent a procedure for prolapse and hemorrhoids (PPH) under CSEA. Anesthesia and surgery were uneventful. However, the patient gradually experienced urinary retention, lower abdomen and back pain, changes in bowel habits and neurological dysfunction of the lower limbs when the catheter was removed. It was later determined that the patient had Tarlov cyst at the left S1 level in the sacral canal. Finally, the patient completely recovered 20 days after drug conservative therapy onset., Conclusion: This case suggests that CES might occur even after ordinary CSEA. The risk factors are drug neurotoxicity to ropivacaine and Tarlov cyst, which helped to accumulate ropivacaine. The development of ultrasound-guided CSEA and an ultrasound atlas of the spinal canal are required., (© 2023. The Author(s).)

Cauda equina syndrome is a rare but severe neuro-spinal disorder commonly caused due to lumbar disc herniation, which occurs mostly at lower levels of L4-S1. We report a case of 38-year-old male soldier deployed on a foreign mission who presented to a level 1 military hospital 4 months back with complaints of decreased movement of bilateral lower limbs and severe low back pain radiating to the right lower limb for 2 hours. He was referred to a higher centre and diagnosed with cauda equina syndrome due to massive disc herniation at levels L2-L3. He underwent laminotomy and discectomy of the extruded intervertebral disc after 48 hours. On subsequent follow-up, his bladder and lower limbs sensations were normal however, he had bowel incontinence, hypotonia, hyporeflexia, and no significant improvement in power. Hence, early diagnosis, referral, and timely intervention affect the outcomes in a cauda equina syndrome patient., Keywords: case reports; cauda equina syndrome; disc herniation; low back pain; military personnel.

Rationale: In recent clinical follow-up, it has been vertified that resorption in lumbar disc herniation (LDH) could be of great curative effect in non-surgical treatment for LDH. However, reports of resorption in giant tumor-like LDH are rarely mentioned due to its risk of irreversible neurological damage which could be caused by long-term non-surgical treatment. In our clinical observations, we have found that enhanced MRI helps to distinguish LDH from intradural tumours and to predict the probability of resorption in LDH. We analyzed 8 patients with giant tumor-like LDH who underwent non-surgical treatment, and these patients had resorption during follow-up. All patients were examined with enhanced MRI before treatment, and the type of "bull's eye" sign classification was determined by images. The MRI protrusion volume(VP), resorption rate(HR%) and JOA score of patients at the first visit and the last follow-up were recorded., Patient Concerns: 8 patients of Han ethnicity were admitted to the department of orthopedic complaining of low back pain for 1week to 12months. They were diagnosed with giant tumor-like LDH by enhanced MRI., Diagnoses: These patients were diagnosed with giant tumor-like LDH., Interventions: We adopted a non-surgical treatment plan for the patients, including taking oral non-steroidal anti-inflammatory agents and performing rehabilitation exercise. In consideration of the risk of irreversible neurological damage, patients were closely observed during treatment and follow-up. Once the following conditions occur, surgical treatment is required immediately: The symptoms are not signifcantly relieved after 3 to 6 months of non-surgical treatment; The symptoms are aggravated by non-surgica treatment; The clinical manifestations of cauda equina syndrome., Outcomes: After treated with oral non-steroidal anti-inflammatory agents and rehabilitation exercise, the resorption was accompanied by clinical symptom relief. No neurological damage occurred in all patients, and the clinical symptoms did not recur in the subsequent follow-up., Lessons: Clinicians should fully consider the possibility of resorption prior to surgical treatment in patients with giant LDH. We can predict the probability of resorption in patients with giant LDH based on enhanced MRI. For patients with a high probability of resorption, we can choose non-surgical treatment in the absence of progressive neurological impairment and cauda equina syndrome., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

A 56-year-old woman experienced persistent excruciating pain with peroneal nerve injury in the anterior aspect of the lower leg after knee surgery. In our pain clinic, we diagnosed the patient with complex regional pain syndrome and performed lumbar sympathetic neurolysis (LSN) with absolute alcohol at the 3rd lumbar vertebra (L3). After the next follow-up, she complained of continuous dull low back pain, anal dysregulation, and fecal incontinence. We performed magnetic resonance imaging (MRI) to rule out other existing pathologies of back pain. On MRI, the nucleus pulposus was moderately extruded to the central zone with inferior sequestration at L2/3, and moderate central canal stenosis was observed at L2/3. She underwent partial laminectomy with discectomy at L2 level. We were not sure of the cause of disc herniation, but we strongly suspected that LSN at the L3 vertebral level was related to the pathology. Therefore, we discuss this unusual case., (Copyright: © Neurosciences.)

Introduction: Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts., Clinical Presentation: A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved., Conclusion: CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Introduction: Cysticercosis, caused by Cysticercus cellulosae, is one of the common parasitic diseases that can affect the central nervous system (neurocysticercosis, NCC). Isolated involvement of cysticercosis of the spine, without the involvement of the brain, has been very rarely reported., Case Presentation: This report presented a case, who was presenting with low back pain with radiation and cauda equina syndrome (CES). On MRI, the patient was found to have a subarachnoid cystic lesion at the level of lumbosacral vertebrae. Under neurosurgery, the patient underwent L5/S1 laminectomy, decompression, and excision of the cyst. On histopathological examination, the patient was diagnosed of having Cysticercosis. Immediately after surgery, the patient had neurological deterioration. However, at the end of 1 year, the patient had significant improvement both neurologically and functionally., Discussion: Spinal NCC should be considered in the differential diagnosis for a patient, who presents with a cystic lesion in the spinal subarachnoid space. Surgical exploration and excision of the cysts should be conducted not only to establish the diagnosis but also to decompress the cord and peripheral nerves., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

The true incidence of haemangiomas, which are the most common benign tumours in the spine, is not known as they are most often asymptomatic and are detected at autopsy. It can become symptomatic due to the haemodynamic and hormonal changes in pregnancy which cause sudden expansion of the lesion. In this paper, we present a case of a woman in her 30s, primigravida at 31 weeks' gestation with acute urinary retention and neurological features suggestive of cauda equina syndrome. Imaging confirmed the diagnosis of vertebral haemangioma involving T12 vertebra encroaching the posterior dural space and abutting the cord. She underwent surgical excision of the haemangioma with complete recovery of neurological symptoms on postoperative follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Cauda equina syndrome (CES) is a rare condition that occurs from multiple nerve root compression. It is considered a surgical emergency because it can lead to permanent neurological damage. There is limited literature regarding management and prognosis of CES for pregnant patients, leaving providers with many questions when encountering patients with this condition. We describe the case of a patient who developed CES during pregnancy. She presented at 30 weeks gestation and successfully underwent surgical decompression in prone position. She later delivered via elective caesarean at term. This case highlights management considerations for pregnant patients with CES, including positioning during surgery and use of regional anaesthesia., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Primary epidural Ewing's sarcoma in the lumbar spinal canal is a rare condition and very few cases are reported in the literature., Case Report: A fifteen-year-old girl presented with low backache associated with sudden onset of weakness and radiculopathy of both lower limbs for 10 days, bowel and bladder involvement for 3 days. Physical examination revealed grade 0/5 power and absent sensations below L4 dermatomal level and perianal region (ASIA A). Plantar reflex was mute bilaterally. Magnetic resonance imaging revealed an extradural lesion within the spinal canal at the L3-L4 level. The patient underwent an emergency posterior decompression, extradural lesion excision and instrumented stabilization L3-L5. Based on histopathological examination of the tissue specimen, we diagnosed the lesion as Ewing sarcoma., Discussion: Primary extra-skeletal Ewing's sarcoma presenting as an epidural lesion in the lumbar spine is a rare clinical entity that should be considered as a differential for spinal epidural lesions. Treatment for such cases is almost always an early surgical intervention due to its rapid onset and compressive neurological symptoms. Wide decompression with instrumented fusion and excision of the lesion followed by chemo and radiotherapy are recommended., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Introduction: Posterior epidural migration of lumbar disc fragment (PEMLDF) is a very rare condition that may lead to a serious neurological deficit such as cauda equina syndrome. Magnetic resonance imaging (MRI) findings can often result in cases of PEMLDF being misdiagnosed as extradural masses of other origin or epidural hematomas. In this study, we reported four additional cases of PEMLDF and reviewed the relevant literature., Patient Concerns: We present four patients with PEMLDF. The mean age of the patients was 53.5 years. Two patients suffered from cauda equine syndrome, and the other two patients complained of radiculopathy., Diagnosis: The MRI findings in each case showed masses with slightly high signal intensity in T2-weighted images, as well as heterogenous and peripheral rim enhancement after contrast enhancement. In some patients there was a tract-like enhancement extending from the outer aspect of the disc to the posterolateral epidural space. A definitive diagnosis was made intraoperatively., Interventions: We performed laminectomy and discectomy in all patients., Outcomes: The PEMLDF patients with radiculopathy had no complaints of weakness or pain after surgery. Both patients with cauda equine syndrome showed a total recovery post-surgery., Conclusions: Early diagnosis and treatment via laminectomy and discectomy is critical to achieving the best postoperative outcomes. Understanding the patient's history, recognizing the similar signal intensity of the mass and intervertebral disc on MRI scans, and looking for peripheral rim enhancement, are the keys to the correct diagnosis of PEMLDF., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Biportal endoscopic spine surgery (BESS) is extending its application to most kind of spine surgeries. Postoperative spinal epidural hematoma (POSEH) is one of the major concerns of this emerging technique. Through this study we aim to investigate the incidence of POSEH in BESS comparing to a conventional spine surgery (CSS).The patients who underwent a non-fusion decompressive spine surgery due to degenerative lumbar spinal stenosis (LSS) or herniated lumbar disc (HLD) or both between January 2015 and March 2019 were reviewed retrospectively. The incidence of clinical POSEH that demanded a revision surgery for hematoma evacuation was compared between CSS and BESS. As a second endpoint, the morphometric degree of POSEH was compared between the two groups. The maximal compression of cauda equina by POSEH was measured by 4 grade scale at the T2 axial image and the neurological state was evaluated by 5 grade scale. The indication of hematoma evacuation was more than hG3 with more than nG1. As a subgroup analysis, risk factors of POSEH in BESS were investigated.The 2 groups were homogenous in age, sex, number and level of operated segments. There was significant difference in the incidence of symptomatic POSEH as 2/142 (1.4%) in CSS and 8/95 (8.4%) in BESS (P = .016). The radiological thecal sac compression by hematoma was hG1 65 (61.3%), hG2 35 (33.0%), hG3 5 (4.7%), hG4 1 (0.9%) cases in CSS and hG1 33 (39.8%), hG2 25 (30.1%), hG3 22 (26.5%), hG4 3 cases (3.6%) in BESS. The difference was significant (P < .001). In BESS subgroup analysis, the risk factor of high grade POSEH was bilateral laminectomy (OR = 8.893, P = .023).The incidence of clinical and morphometric POSEH was higher in BESS. In BESS, POSEH developed more frequently in bilateral laminectomy than unilateral laminectomy., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

A 45-year-old man had recurrent presentations with pleuritic chest pain and shortness of breath. Four months prior, he had developed cauda equina syndrome from a spinal epidural abscess in the setting of intravenous drug use, complicated by lasting neurological deficits and a rectal prolapse. On his final presentation, blood cultures taken in the absence of antibiotics grew Enterococcus faecalis from multiple sets. A transoesophageal echocardiogram confirmed tricuspid valve endocarditis. He recovered well post-targeted long-term antibiotics. Endoscopy confirmed a chronic rectal prolapse with multiple ulcers and was hypothesised as the source of bacteraemia. He subsequently underwent perineal rectosigmoidectomy. This uncommon sequela of rectal prolapse highlights several issues, including the management of neurogenic bowel dysfunction following spinal cord injury and the importance of early prolapse recognition and management. Finally, appropriate collection of blood cultures and correct use of echocardiography are critical steps in investigating infective endocarditis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Vocal fold paralysis and cauda equina syndrome are very rare neurologic deficits. This report describes the case of a patient who simultaneously developed both after uneventful spinal-epidural anesthesia with 0.5% hyperbaric bupivacaine., Patient Concerns: We report the case of a 45-year-old female, who underwent surgery for bilateral hallux valgus developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered. There was no pain or paresthesia during needle placement or drug injection. Surgery was performed uneventfully., Diagnoses: Right vocal fold paralysis was diagnosed with flexible laryngoscopy., Interventions: Patient was started on the treatment with a surgery for bilateral hallux valgus, who developed cauda equina syndrome and unilateral vocal fold paralysis after uneventful spinal-epidural anesthesia was administered., Outcomes: Postoperatively, she had difficulty in urination and defecation. In addition, she developed unilateral vocal fold paralysis characterized by hoarseness, effortful voice production, and choking with liquids. Magnetic resonance imaging performed on the lumbosacral area and computed tomography of the neck, the chest, and the skull revealed entirely normal results. However, flexible laryngoscopy revealed a right vocal fold paralysis. Although cauda equina syndrome can occur due to neurotoxicity of local anesthetics, the exact etiology of vocal fold paralysis is uncertain., Lessons: The case highlights that 2 rare and serious complications of spinal-epidural anesthesia can even occur in the same patient after uneventful surgery and block performance., Competing Interests: The authors have no conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

A 67-year-old man presented to his general practitioner with intermittent episodes of unilateral sciatica over a 2-month period for which he was referred for an outpatient MRI of his spine. This evidenced a significant lumbar vertebral mass that showed tight canal stenosis and compression of the cauda equina. The patient was sent to the emergency department for management by orthopaedic surgeons. He was mobilising independently, pain free on arrival and without neurological deficit on assessment. Clinically, this patient presented with no red flag symptoms of cauda equina syndrome or reason to suspect malignancy. In these circumstances, National Institute for Health and Care Excellence guidelines do not support radiological investigation of the spine outside of specialist services. However, in this case, investigation helped deliver urgent care for cancer that otherwise may have been delayed. This leads to the question, do the current guidelines meet clinical requirements?, Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Study Design: Multicenter prospective cohort., Objective: To discern neurological- and functional recovery in patients with a traumatic thoracic spinal cord injury (TSCI), conus medullaris syndrome (CMS), and cauda equina syndrome (CES)., Setting: Specialized spinal cord injury centers in Europe., Method: Lower extremity motor score (LEMS) and spinal cord independent measure (SCIM) scores from patients with traumatic TSCI, CMS, and CES were extracted from the EMSCI database. Scores from admittance and during rehabilitation at 1, 3, 6, and 12 months were compared. Linear mixed models were used to statistically analyse differences in outcome, which were corrected for the ASIA Impairment Scale (AIS) in the acute phase., Results: Data from 1573 individuals were analysed. Except for the LEMS in patients with a CES AIS A, LEMS, and SCIM significantly improved over time for patients with a TSCI, CMS, and CES. Irrespectively of the AIS score, recovery in 12 months after trauma as measured by the LEMS showed a statistically significant difference between patients with a TSCI, CMS, and CES. Analysis of SCIM score showed no difference between patients with TSCI, CMS, or CES., Conclusion: Difference in recovery between patients with a traumatic paraplegia is based on neurological (motor) recovery. Regardless the ceiling effect in CES patients, patients with a mixed upper and lower motor neuron syndrome (CMS) showed a better recovery compared with patients with a upper motor neuron syndrome (TSCI). These findings enable stratifications of patients with paraplegia according to the level and severity of SCI.

Background: Cauda equina syndrome (CES) is a rare and serious syndrome that requires urgent surgery to improve neurological symptoms. CES can be caused by lumber disc herniation (LDH) and accounts for about 1% to 3% of all cases of disc herniation., Objectives: The purpose of this study was to analyze the characteristics and outcomes of the cases of patients with CES caused by LDH and treated by percutaneous endoscopic lumbar discectomy (PELD)., Study Design: This study used a retrospective design., Setting: Research took place at the Jiangyin Hospital affiliated with Nanjing University of Chinese Medicine, Jiangsu, China., Methods: This was a retrospective study of patients treated for CES due to LDH with PELD as an emergent surgery at a single institutional department between January 2015 and March 2018. The following variables were analyzed: age, gender, the level of disc prolapse, time interval between diagnosis and surgery, lower extremity pain or weakness, perianal sensation, voluntary anal contraction, presence of bladder dysfunction, and the reversal of these deficits in follow-up., Results: After the emergent surgery with PELD, the lower extremity symptoms were all completely recovered or partly decreased. Only one patient had weakness with plantar flexion of the left foot at the one-year time point. The decreased perianal sensations were partly recovered after surgery, and 9 cases had complete recovery and 2 cases had partial recovery at the one-year follow-up. No patients had anal contraction and bladder problems after the one-year follow-up., Limitations: The number of cases reported here is limited, so we will expand the study by including an increased number of patients and a longer follow-up duration., Conclusion: Taken together, these observations show that PELD, used as a minimally invasive choice of emergent surgery, can provide enough decompression of disc prolapse and a satisfactory outcome for patients with CES caused by LDH., Key Words: Cauda equina syndrome, lumbar disc herniation, outcomes, percutaneous endoscopic lumbar discectomy.

Competing Interests: Competing interests: None declared.

Rationale: Intradural disc herniation has been documented rarely and the pathogenesis remains unclear. The region most frequently affected by intradural lumbar disc herniations is L4-5 level, and the average age of intradural disc herniations is between 50 and 60 years. Although magnetic resonance imaging is a valuable tool in the diagnosis of this disease, it is still difficult to make a definite diagnosis preoperatively., Patient Concerns: In this report, we described a 58-year-old male patient who presented with intermittent pain of low back and radiating pain of the both lower extremities for 2 years as well as decreased muscle strength of the both legs and dysfunction of urinary and defecation for 1 month., Diagnosis: Lumbar disc herniation was diagnosed during the first clinical examination in the local hospital. Magnetic resonance imaging revealed a mass disc filling almost the entire spinal canal at the L4/5 level and a stalk connecting the mass to the intervertebral disc was detected in the sagittal T2-weighted image. The massive lesion caused cauda equina compression, resulting in dysfunction of urinary and defecation., Interventions: Considering the mass's volume, bilateral hemilaminectomy, and transforaminal lumbar interbody infusion were performed. During the surgery, we found a perforation in the ventral dura and major part of herniated disc was located in the intradural space through it. The disc was carefully dissected from the surrounding nerve roots and the ventral dura and then totally removed. The defect on the ventral dura was sutured to prevent cerebrospinal fluid leakage., Outcomes: The patient presented complete recovery of the radiculopathy and cauda equina syndrome and significant improvement of muscle strength of both legs at 12 months follow-up., Lessons: The diagnosis of intradural disc herniations is very difficult and mainly based on intraoperative and histopathological results. Surgical intervention is only effective method to manage this disease and to relieve symptoms and prevent severe neurological deficits.

Background: Spontaneous conus medullaris infarction is a rare disease. We describe two patients with spontaneous conus medullaris infarction presenting as acute cauda equina syndrome and their unique electromyography (EMG) findings., Case Presentation: Two patients developed acute low back pain with mild asymmetric paraparesis, loss of perianal sensation and sphincter dysfunction. Ankle deep tendon reflexes were reduced in bilaterally. Neither patient had cardiovascular risk factors. Magnetic Resonance imaging showed infarction in the conus medullaris. Functional recovery was good in both patients, but progressive asymmetric calf wasting and sphincter dysfunction remained. EMG studies at follow-up of at least 3 years demonstrate active denervation at the muscles innervated by the first sacrum anterior horn cells., Conclusion: Spontaneous conus medullaris infarction can occur in healthy individuals and presents as cauda equina syndrome. Findings of needle EMG studies indicate a progressive course of sacrum anterior horn cell disorder during long-term follow-up.

Seventeen cases of infections in spinal structures were reported 2010-2017 to the Swedish Health and Social Care Inspectorate (IVO), a government agency responsible for supervising health care, for missed or delayed diagnosis. All patient records were scrutinized in order to find underlying causes and common factors. The delayed diagnoses were equally found among men and women and most frequent in in the age-group 65 to 79 years of age. The diagnostic delay most probably in many cases led to patient harm and avoidable sequelae, many with severe impairment for daily life. Several of the patients had a locus minoris resistentiae in the spine and in several cases the entry port of infections were cutaneous wounds, for example leg ulcers. The most important finding was that in the majority of cases the clinical investigation was inadequate and the clinical follow-up - while in hospital! - was inferior, without documentation of muscular weakness and sensory loss. In several cases a too passive management was found, when the losses eventually had become apparent, delaying surgical interventions.

Background: Failing to recognise the signs and symptoms of subarachnoid haemorrhage (SAH) causes diagnostic delay and may result in poorer outcomes. We report a rare case of SAH secondary to a vertebral artery dissection (VAD) that initially presented with cauda equina-like features, followed by symptoms more typical of SAH., Case Presentation: A 55-year-old man developed severe lower back pain after sudden movement. Over the next 5 days he developed paraesthesiaes in the feet, progressing to the torso gradually, and reported constipation and reduced sensation when passing urine. On day six he developed left facial palsy, and later gradual-onset headache and intermittent confusion. Magnetic resonance imaging of the brain showed diffuse subarachnoid FLAIR hyperintensity, concerning for blood, including a focus of cortical/subcortical high signal in the left superior parietal lobule, which was confirmed by computed tomography. Digital subtraction angiography demonstrated a left VAD with a fusiform aneurysm., Conclusion: We present a very rare case of intracranial VAD with SAH initially presenting with spinal symptoms. The majority of subsequent clinical features were consistent with a parietal focus of cortical subarachnoid blood, as observed on neuroimaging.

We present an unusual case of spinal neurinoma with intralesional and subarachnoid bleeding with acute cauda equina syndrome. A 38-year-old man was admitted to our department after a minor thoracic spinal trauma with right lower limb plegia and urinary retention. MRI showed a T11 intradural tumour with intralesional and subarachnoid haemorrhage. The patient was operated of spinal cord decompression and complete tumour resection. The histological examination documented a schwannoma with large haemorrhagic intratumoural areas. A full neurological recovery was documented at 6-month follow-up., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Rationale: Cauda equina syndrome (CES) refers to a group of symptoms that occur when the nerves in the cauda equina become compressed or damaged. The most common etiology of CES is lumbar intervertebral disc herniation, but CES following lumbar spinal surgery is rare, especially without motor dysfunction. Herein, we illustrate a case of CES that developed as a complication of spinal surgery and to deduce its possible underlying cause., Patient Concerns: A 46-year-old man experienced lumbago, bilateral shank pain, and numbness with neurogenic claudication for 3 years due to degenerative lumbar disc herniation and spinal cord stenosis. After a thorough examination to diagnose lumbar spinal stenosis, the patient underwent bilateral decompression and pedicle screw system internal fixation with bone graft. Postoperatively, the patient showed regained strength in his bilateral shanks, and he did not complain of lumbago and shank pain, but CES occurred, which manifested as underpants-type numbness in the perineum without bladder, anal, and motor dysfunction., Diagnoses: CES as a postoperative complication of lumbar stenosis., Interventions: The patient underwent bilateral laminectomies, partial facetectomies, and pedicle screw system internal fixation and fusion with bone graft. Postoperatively, the patient performed adequate rehabilitation exercises and was expected to recover spontaneously., Outcomes: The symptoms of pain and claudication resolved after 3 weeks in the hospital, but an underpants-type hypoesthesia in the perineum without motor dysfunction developed. The patient experienced full recovery from CES 6 months after surgery., Lessons: CES as a complication of lumbar spinal surgery is very rare. Excessive sensitivity to the traction of the dural sac was, in our opinion, the most possible cause of postoperative CES in this case. When the nerve root is pulled intraoperatively, it is best not to cross the central line of the spinous process. The plane of the nerve retractor needs to be parallel to the dural sac at the pulling point to reduce the formation of shear force. Most importantly, gentle maneuver is required because sensitivity to the traction of the dural sac varies individually.

Introduction: Lumbar disc herniation during pregnancy poses a significant challenge to the spine surgeon towards achieving good clinical, maternal, and fetal outcomes. Surgical intervention is warranted in patients with significant neural deficits, and cauda equina syndrome and needs to be performed at the earliest in order to avoid irreversible neurological sequelae., Case Presentation: We report a 29-year-old primigravida in her 21st week of gestational period, who was diagnosed with cauda equina syndrome secondary to two level lumbar disc herniations. The lengthier surgical duration in performing double level disc herniations in an obese patient raises concerns in anesthetic dosing of drugs and surgical positioning which may result in fetal distress. A double level decompression and discectomy in prone position was done under general anesthesia. Despite the surgical challenges, the postoperative period was uneventful resulting in immediate pain relief and complete neurological recovery, followed by the delivery of a 2.7-kg healthy male child., Discussion: Surgical intervention can be performed in pregnancy, to avoid irreversible neurological deficits, even in an obese individual with double level lumbar pathology. However, it is essential that the surgeon appraises the situation and involves an integrated multidisciplinary team comprising anesthetist, spine surgeon, obstetrician, and psychologist, and inculcates certain precautions in the perioperative management to achieve good surgical and fetal outcomes., Competing Interests: Compliance with ethical standardsThe authors declare that they have no conflict of interest.

This study aims to analyze and summarize the imaging features of spinal atypical teratoid/rhabdoid tumors (AT/RT) in children.Imaging features in 8 children with spinal AT/RT confirmed by surgical pathology were retrospectively analyzed. All patients had underwent total spine 3.0 T magnetic resonance imaging (MRI) and 64-slice spiral computed tomography (CT). Among these 8 patients, head MR non-enhanced and spinal enhanced scanning was applied to 5 patients, while CT examination was applied to 3 patients.All 8 patients were characterized by cauda equina syndrome. The lesions of 7 patients were in the thoracolumbar spinal junction, while the lesion of the remaining patient was in the lumbar spine. Furthermore, among these patients, the lesions of 5 patients were limited to the intraspinal canal (1 lesion in the epidural space, and 4 lesions in the subdural space), while the lesions of 3 patients invaded the paravertebra (2 lesions in the epidural space and 1 lesion in the subdural space). Three or more spinal segments were invaded by tumors in 7 patients, while sacral canal was affected in 5 patients. All 8 patients experienced bleeding in the tumors. Enhanced MRI revealed meningeal enhancement in 6 patients, and bilateral nerve root enhancement in 4 patients. The masses in 3 patients brought damages to the intervertebral foramen or sacral pore. The lesion of 1 patient was featured by skip growth. One patient had total spinal metastasis and 3 had hydrocephalus. The masses in 2 patients had a slightly low density when detected by CT, and enhanced scanning revealed a mild to moderate enhancement.Spinal AR/TR had the following characteristics: children were characterized by cauda equina syndrome; the mass that invaded the thoracolumbar spinal junction and the extramedullary space of multiple segments grew along the spinal longitudinal axis; bleeding mass was revealed in MRI imaging; meninges, nerve root, and sacral canal metastases occurred. The gold standard for the definite diagnosis of AT/RT is biopsy combined with immunohistochemistry.

Postoperative cauda equina syndrome (CES) is a known rare complication following lumbar disc surgery. Seldom are they seen following decompression for spinal stenosis and may be actually more frequent and under-reported? Emergent surgical exploration remains the mainstay of management as the factors responsible for postop CES remains a variety of compressive forces. Yet many a time postoperative imaging or surgical exploration fails to identify a pathology and this leads to an ischaemic theory responsible for CES. Our article highlights conservative management in these selective group. We share our experience in two cases of incomplete CES during our routine transforaminal interbody fusion which we followed closely without re-exploration eventually ending in a favourable outcome. Key messages : The factors responsible for postop CES remains mostly a variety of compressive forces though in some instances postoperative imaging or surgical exploration fails to identify such in some cases. This leads to an ischaemic theory responsible for CES. The role of conservative management of postoperative CES in certain selective cases has a favourable outcome as illustrated in our cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Study Design: Cross-sectional phenomenological qualitative study., Objectives: To investigate women's experience of sexuality after spinal cord injury (SCI) with a focus on rehabilitation and manging practical impact., Setting: Women with SCI living in the community in United Kingdom (UK)., Methods: Participants were recruited via three UK SCI centres, ensuring tetraplegia, paraplegia and cauda equina syndrome representation. Single semi-structured interviews exploring individual's experiences around sexuality following SCI were recorded and transcribed for thematic analysis., Results: Twenty-seven women aged 21-72 years, sexually active since SCI were interviewed, each lasting 17-143 min (mean 55 min). Six key themes emerged: physical change, psychological impact, dependency, relationships and partners, post injury sexual life and sexuality rehabilitation., Conclusions: Sexuality remains an important, valued aspect of female identity following SCI; sexual activity continues and though altered remains enjoyable and rewarding. Sexuality rehabilitation should commence early, preparing women for altered sexual sensation, disclosure of altered sexual function to partners, and encouraging early self-exploration. Techniques optimising continence management in preparation for and during sex should be taught. Participants identified a need for women-only education and support groups, increased peer support, self-esteem, communication and social skills training and even fashion advice and pampering sessions during rehabilitation. Support and education for partners are needed. Staff require support to be knowledgeable and confident in addressing women's sexuality needs. Use of the Ex-PLISSIT model for psychosexual support could help staff to better meet these needs.

Objective We assessed our results of short-segment decompression and fixation for osteoporotic thoracolumbar fractures with neurological deficits. Methods We evaluated 20 elderly patients (age, 60-89 years; mean, 73.2 years) with osteoporotic thoracolumbar fractures and neurological deficits. They underwent short-segment decompression and fixation and followed up for 40.6 (range, 24-68) months. A visual analog scale (VAS) and the Oswestry Disability Index (ODI) were used to measure back pain and disability. We also analyzed patients' radiologic findings and neurological status. Perioperative and postoperative complications were recorded. Results At the latest follow-up, the average VAS score for back pain and ODI scores had significantly improved. The radiologic assessment showed significant improvements in local kyphosis, anterior vertebral height, and the vertebral wedge angle compared with the original measures. Neurological function also improved in 18 of 20 patients. No major complications occurred perioperatively. Our techniques included preservation of the posterior ligament complex, decortication of facet joints for fusion, no tapping to increase the screw insertional torque, pre-contouring of the rods according to the "adaptive" curve obtained from postural reduction, and postoperative spinal bracing. Conclusions Posterior short-segment decompression and fixation could be an effective surgical option for osteoporotic thoracolumbar burst fractures with neurological deficits.

Competing Interests: Informed consent was obtained from the patient and there were no conflicts of interest

The primitive neuroectodermal tumors (PNETs) of the spine are rare. They are usually intramedullary and reported in children. We herein report an epidural PNET of lumbosacral area presenting with the cauda equina syndrome in an adult. A 38-year-old woman presented to our emergency room with acute onset lower extremity weakness and urinary incontinence. Emergent magnetic resonance imaging revealed a mass lesion isointense on T1-weighted and heterogeneously hyperintense in T2-weighted images in the epidural lumbosacral area. The patient underwent emergent laminectomy of L1-L3 and total resection of the lesion. The patient"s neurological examination improved dramatically after the surgery and after 6-month of follow-up, she was neurologically intact. The histopathological and immunohistochemical evaluations revealed PNET. Epidural PNET of the spinal column, although rare, can present with an acute neurological deficit. Surgery remains the treatment of choice and immunohistochemistry is required for confirming the diagnosis.