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Objective and Importance: The ventriculus terminalis of the conus, or "fifth ventricle" refers to the ependymal-lined space in the middle of the conus that is present in childhood and whose persistence into adulthood is rare. A number of cases of cystic dilatation of the ventriculus terminalis have been described in adulthood. Patients tend to present with either pain alone or gradually progressive conus or cauda equina syndromes with varying degrees of recovery after cyst drainage. Presentation with an acute cauda equina syndrome and its successful surgical management has not been previously reported., Clinical Presentation: A 57-year-old woman experienced back pain and bilateral sciatica ascribed to diabetic neuropathy for 2 years. Over a 24-hour period she developed bilateral lower extremity weakness, saddle anesthesia, and bowel and bladder incontinence. Lumbosacral magnetic resonance imaging demonstrated a large cystic dilatation of the ventriculus terminalis., Intervention: She was taken for emergency surgical decompression and cyst drainage. Immediately after surgery, she experienced significant increase in lower extremity strength and has since regained continence., Conclusion: Cystic dilation of the ventriculus terminalis should be part of the differential diagnosis for a cauda equina syndrome; surgical decompression with simple cyst drainage can result in excellent clinical results.

Although most workers who sustain lower back can be managed without surgery, a carefully selected subset of patients benefit from operative intervention. When evaluating these patients, care must be taken to identify surgical emergencies, including patients with cauda equina syndrome and progressive neurologic deficits and patients with cauda equina syndrome and progressive neurologic deficits and patients with certain historical red flags that should prompt further evaluation. Conditions that may benefit from surgery include lumbar disc herniations, discogenic back pain, spinal stenosis, and spondylolisthesis. This article reviews the indications for surgery in injured workers and expected postoperative outcomes.

Objective: To report synovial cysts associated with cauda equina syndrome in 2 dogs., Study Design: Clinical cases., Animals: Two German Shepherd dogs., Methods: After magnetic resonance imaging detection, cysts were surgically removed via dorsal laminectomy., Results: Six and 8 months after surgery, both dogs were free of clinical signs and no pain was elicited on lumbosacral joint manipulation., Conclusion: Although described in dogs, cysts at the lumbosacral joint might cause compression of the cauda equina nerve roots. Radical excision of the cyst capsule can result in resolution of clinical signs., Clinical Relevance: Synovial cysts should be considered in the differential diagnosis of dogs with cauda equina compression syndrome when lumbosacral degenerative joint disease is present.

Study Design: Case report., Objectives: To report a case of lumbar hemangioma causing neurogenic claudication and early cauda equina, managed with hemostatic vertebroplasty and posterior decompression., Summary of Background Data: This is the first report to our knowledge of a lumbar hemangioma causing neurogenic claudication and early cauda equina syndrome. Most hemangiomas causing neurologic symptoms occur in thoracic spine and cause spinal cord compression. Vertebroplasty as a method of hemostasis and for providing mechanical stability in this situation has not been discussed previously in the literature., Methods: L4 hemangioma was diagnosed in a 64-year-old woman with severe neurogenic claudication and early cauda equina syndrome. Preoperative angiograms showed no embolizable vessels. Posterior decompression was performed followed by bilateral transpedicular vertebroplasty. The patient received postoperative radiation to prevent recurrence., Results: Complete relief of neurogenic claudication and cauda equina with less than 100 mL of blood loss., Conclusion: A lumbar hemangioma of the vertebral body, although rare, can cause neurogenic claudication and cauda equina syndrome. Intraoperative vertebroplasty can be an effective method of hemostasis and provide stability of the vertebra following posterior decompression.

Posterior epidural migration of free disc fragments is rare, and posterior migration of the free fragments causing cauda equina syndrome is exceptionally rare. This report describes a 53-year-old man with disc fragment extrusion at the levels of L3-4 and a 54-year-old man with disc fragment extrusion at L5-S1 intervertebral space. The patients responded well to the operative therapy with complete relief of the symptoms. The pathological examination confirmed that the specimen was a degenerated intervertebral disc. Early surgery should be the first choice of therapy in patients with large posteriorly migrated sequestered disc fragments, to prevent severe neurological deficits such as cauda equina and conus medullaris syndromes.

Objective: Our aim was to study the outcomes and results of surgically treated patients with synovial cysts of the lumbar spine in our institution., Methods: Retrospective data from 39 consecutive patients, treated during the period of December 1996 to August 2004, were analyzed. Twenty-eight men (70%) and 11 women (30%) of mean age 63.3 years were studied. All pre- and postoperative signs, symptoms, extension/flexion radiographs, magnetic resonance imaging (MRI), and computed tomography (CT) with or without myelography were reviewed. All underwent surgery for synovial cysts with excision and decompression. Additional fusion in 26 patients was performed; 22 of them had degenerative spinal spondylolisthesis. Nine (23%) patients had prior decompression procedures, with three (8%) having had prior spinal instrumentation. Surgical outcomes were evaluated according to a questionnaire scoring system (scale of 1-4; 4 = excellent, 3 = good, 2 = fair, 1 = poor). Various preoperative attributes such as gender, age, weight, and height were analyzed to see if they had any effect on the outcome of surgery. Modified musculoskeletal outcomes data evaluation and management system (MODEM), questionnaire was provided to all; 24 (62%) responded. The following categories were determined: excellent (<20), very good (21-40), good (41-60), fair (61-80), and poor (81-100). Postoperative complications were also recorded., Results: All patients had pain in their lower extremities, with 62% experiencing pain bilaterally. Ninety-five percent had pain in their back and 36% in the buttocks (36%). Eighteen (46%) patients had CT myelography. A total of 42 cysts were found. Two patients had bilateral cysts at L4-L5 level. Histology revealed two hemorrhagic cysts. The average duration of surgery was 231 minutes (range 92-391 minutes), and a mean blood loss of 930 mL (range 200-2500 mL) was recorded. Two operative dural tears and one postoperative wound dehiscence were observed. One patient had a recurrent synovial cyst at the site of original surgery. Eight patients (four each in the fusion and nonfusion group) had junctional degeneration and symptoms. A regression analysis performed on age, height, weight, and gender showed that they were not determining factors of surgical outcome. Surgery of spinal cysts at L4-L5 segment produced good and those at L5-S1 and multilevel excellent results. Patients with spinal segment fusion had superior outcomes, with 80% having excellent or good outcomes versus approximately 70% without fusion. With the modified MODEM questionnaire, 22 of the 24 (92%) patients scored between excellent, very good, and good. Two patients scored in the fair range, and none of the 24 patients scored in the range of poor., Conclusions: Spinal cysts are commonly found at the L4-L5 level, the site of maximum instability. MRI is the tool of choice for diagnosis. The etiology is still unclear, but underlying spinal instability has a strong association for formation of spinal cysts and worsening symptoms. Synovial cysts resistant to conservative therapy should be treated surgically. Resection and decompression with fusion remain an appropriate option. The optimal approach for patients with juxtafacet cysts remains unclear. The best surgical treatment approach for each particular individual appears to remain speculative.

The authors report on a patient in whom monoradicular pain was caused by ganglionitis of a spinal nerve. Neuroimaging and intraoperative findings identified what were thought to be tumorlike changes in the affected nerve root. The neuropathological examination, however, revealed typical signs of ganglionitis. This rare inflammation usually appears with viral infections, as part of paraneoplastic symptoms, or in the presence of Sjögren disease. Because all of these differential diagnoses were negative in the treated patient, chronic nerve root compression due to disc herniation was suspected as the causative factor for the spinal ganglionitis.

Low back pain is an extremely common complaint encountered by emergency and primary care physicians. Although the majority of patients have uncomplicated benign presentations, there is a small subset who has a much more severe disease process called cauda equina syndrome, which entails acute compression of the nerve roots of the cauda equina. These patients usually present posttraumatically with the triad of saddle anesthesia, bowel or bladder dysfunction, and lower extremity weakness. Significant morbidity can result from delayed diagnosis and treatment; therefore, the emergency physician should remain aware of this potential orthopedic pitfall. This case report discusses the clinical presentation, diagnosis, and relevant treatment of cauda equina syndrome in the ED.

To obtain easier access to avulsed roots in the intradural space for patients suffering cervical root avulsion, the authors of this study developed a novel repair method. This involves using nerve grafts to bridge corresponding segments of the spinal cord and the trunk or cord level of the plexus, respectively, in two surgical stages. All eight patients admitted to this study received pre- and post-operative workups of electrophysiological evaluations and muscle power grading through Medical Research Council (MRC) scores. The degrees of impairment were also graded according to a modified version of Dumitru's and Wilbourn's scale (mild = 1; moderate = 2; severe = 3). The preoperative versus post-operative differences in the severity of the injuries and in the grading of the target muscle power were calculated according to the Wilcoxon signed-rank test. The preoperative degree of the severity of the injuries, as measured by electromyography (EMG), was 3.00 +/- 0.00 (mean +/- S.D.). The post-operative result was 2.125 +/- 0.641. Significant change took place after repair (P = 0.0313). Moreover, although little improvement was observed in the triceps, brachioradialis (BR), extensor carpi radialis (ECR), flexor digitorum profundus (FDP) and intrinsic hand muscles, the MRC grading showed significant yet not prominent motor recovery in the deltoid and biceps brachii (both P = 0.0313). We were impressed that the initial significant statistical results of differences in pre- and post-operative severity of the injuries and muscle power grading, demonstrated that regeneration does occur with this repair strategy.

Metastasis of renal clear cell carcinoma to the spinal cord are quite rare. Intradural localization causing a cauda equina syndrome has been previously reported only in two cases. The present report details the clinical, surgical and neuroradiological findings of a third case requiring emergency surgery, and presents data available from a brief review of cases reported in the literature. From the data available in the literature, we suggest that cerebral and spinal MRI and PET imaging should be widely performed in the staging of patients treated for renal clear cell carcinoma, in order to early detect CNS involvement.

Objective: To compare the characteristics, presentation, and surgical outcome of patients with microdiscectomies at L1-L2 and L2-L3 with those we treated at L3-L4. We further sought to compare these results with those reported in the literature for discectomies at the L4-L5 and L5-S1 levels., Methods: We reviewed the clinical data collected from 69 patients who had 72 L1-L2, L2-L3, and L3-L4 microdiscectomies performed from 1989 to 1999 at the New York University Medical Center. Patients who had surgery at L1-L2 or L2-L3 were grouped and compared with those treated at the L3-L4 level. Patients' charts were retrospectively reviewed at a mean of 12.9 months after surgery for presenting signs and symptoms, patient characteristics, and surgical outcome. Long-term follow-up via telephone interview was obtained at an average of 81.3 months after surgery., Results: In the L1-L2 + L2-L3 group, 58% of the patients had previous lumbar disc surgery, compared with only 10% of those in the L3-L4 group, and 20% in the L1-L2 + L2-L3 group required a fusion during the procedure compared with only 10% in the L3-L4 group. These differences are both statistically significant. The short-term chart review demonstrates that only 58% and 53% of patients in the L1-L2 + L2-L3 group were improved with regard to radicular and back pain, respectively, whereas those in the L3-L4 group reported 94 and 87% rates of improvement in the same categories, both highly statistically significant findings. The long-term follow-up confirmed a highly statistically significantly worse outcome in the L1-L2 + L2-L3 group, with only 33% of patients reporting an improvement in their economic or functional status, compared with an 88% rate of improvement in the L3-L4 group. The outcome of our patients with L3-L4 herniations was similar to that reported in the literature for herniations at L4-L5 and L5-S1., Conclusion: Herniated discs at the L1-L2 or L2-L3 level are different entities from those at lower levels of the lumbar spine. The surgical outcome in terms of postoperative back and radicular pain is worse for herniated discs at L1-L2 and L2-L3 compared with those treated at L3-L4. Our patients with L1-L2 or L2-L3 surgically treated herniated discs were more likely to have had previous lumbar surgery and required a fusion more often than their counterparts with L3-L4 herniated discs.

Study Design: Case report., Objective: To report a rare cause of spinal cord compression., Setting: University Hospital, Wales, UK., Case Report: A 67-year-old gentleman on oral anticoagulation for atrial fibrillation presented with a 4-h history of progressive loss of sensation and weakness in both legs; there was no history of trauma. On examination, he had a flaccid paraplegia with altered sensation in the L1,2,3 dermatomes and complete anaesthesia in the L4,5 distribution. Knee and ankle jerk reflexes were absent, plantars were equivocal and anal sphincter tone was reduced. The patient's international normalized ratio (INR) was 4.1. An MR scan showed an extensive intradural haematoma compressing the cauda equina. The anticoagulation was reversed and an urgent T12-L2 laminectomy was performed; findings were a circumferential haematoma at L1 extending in the anterior canal between T10 and L3. The patient had an uneventful postoperative course generally, but at 1 week there was no neurological recovery., Conclusion: This case highlights that anticoagulation even when well controlled is not without risk. This is particularly of concern as the number of patients receiving long-term anticoagulation therapy has doubled between 1993 and 1998.

Study Design: A retrospective study of 87 patients who underwent posterior lumbar interbody fusion (PLIF) at L4-L5 for L4 degenerative spondylolisthesis., Objective: To clarify: 1) the correlation between radiologic degeneration of cranial adjacent segment and clinical results, 2) risk factors for radiologic degeneration of cranial adjacent segment, and 3) preoperative radiologic features of patients who underwent additional surgery with cranial adjacent segment degeneration., Summary of Background Data: Whereas PLIF with pedicle screw fixation has shown satisfactory clinical results, a solid fusion has been reported to accelerate a degenerative change at unfused adjacent levels, especially in the cranial level. Although several authors have reported the adjacent segment degeneration after PLIF, there are no previous reports of risk factors for adjacent segment degeneration after PLIF., Materials and Methods: Eighty-seven patients who underwent PLIF for L4 degenerative spondylolisthesis and could be followed for at least 2 years were included in this study. We measured lumbar lordosis, scoliosis, laminar inclination angle at L3, facet sagittalization at L3-L4, facet tropism at L3-L4, preexisting disc degeneration at L3-L4, and lordosis at the fused segment. Progression of L3-L4 segment degeneration was defined as a condition in which disc narrowing, posterior opening, and progress of slippage in comparison with preoperative dynamic lateral radiographs. Patients were divided into three groups according to postoperative progression of L3-L4 degeneration: Group 1 with neither progression of L3-L4 degeneration nor neurologic deterioration, Group 2 with progression of L3-L4 degeneration but no neurologic deterioration, and Group 3 with an additional surgery required for neurologic deterioration. Correlation between clinical results and radiologic progression of L3-L4 degeneration, and risk factors for progression of radiologic degeneration were investigated. Further, preoperative radiologic features of Group 3 were studied to detect risk factors for clinical deterioration., Results: There were 58 (67%) patients classified into Group 1, 25 (29%) patients into Group 2, and 4 (4%) patients into Group 3. There was no significant difference in average age in each group. No obvious difference was observed in recovery rate between Groups 1 and 2. Laminar inclination angle and facet tropism in Group 3 were more significant than those in Groups 1 and 2. Further, apparent lamina inclination and facet tropism coexisted in Group 3. There were no obvious differences in other factors between each group., Conclusion: 1) There was no correlation between radiologic degeneration of cranial adjacent segment and clinical results. 2) Risk factors for postoperative radiologic degeneration could not be detected in terms of each preoperative radiologic factor. 3) Coexistence of horizontalization of the lamina at L3 and facet tropism at L3-L4 may be one of the risk factors for neurologic deterioration resulting from accelerated L3-L4 degenerative change after L4-L5 PLIF.

Object: The purpose of this study was to analyze therapeutic possibilities and clinical outcomes in patients with lumbosacral plexus injuries to develop surgical concepts of treatment., Methods: In a retrospective investigation 10 patients with injuries to the lumbosacral plexus were evaluated after surgery. The patients were assessed clinically, electrophysiologically, and based on the results of magnetic resonance imaging and computerized tomography myelography. In most patients a traction injury had occurred due to severe trauma that also caused pelvic fractures. In most cases the roots of the cauda equina of the lumbosacral plexus had ruptured. In cases of spinal root ruptures repair with nerve grafts were performed. In cases in which proximal stumps of the plexus could not be retrieved palliative nerve transfers by using lower intercostals nerves or fascicles from the femoral nerve were performed., Conclusions: Lesions of the proximal spinal nerves and cauda equina occur in the most serious lumbosacral plexus injuries. Patients with such injuries subjected to reconstruction of spinal nerves, repair of ventral roots in the cauda equina, and nerve transfers recovered basic lower-extremity functions such as unsupported standing and walking.

In this report the authors present a case of cauda equina syndrome that developed following induction of spinal anesthesia in a patient who had no apparent preexisting bleeding abnormality. An acute subdural hematoma caused the syndrome and was believed to have resulted from direct vascular trauma during administration of spinal anesthesia or from vascular trauma combined with thrombocytopenia in the postoperative period.

Study Design: In this Journal Club review, we critically examine the methodology and results of a recently published meta-analysis describing the time dependency of surgical outcomes associated with cauda equina syndrome (CES) diagnosis., Objectives: Our objectives are to clarify the strengths, weaknesses, and appropriate use of statistics regarding the findings of the previous publication., Summary of Background Data: Surgical outcomes from published reports are related to both preoperative conditions and the time between surgery and diagnosis of CES., Methods: We reexamined many of the papers that were used to create the surgical outcomes data set, including the publications that supplied quantitative information for logistic regression. Of special focus were studies that contributed to the "less than 24 hours from diagnosis" data. The use of statistical parameters such as probabilities and odds ratios to infer possible future outcomes is also addressed to clarify the papers' interpretations. To support the overall limitations of their generalized findings, we conducted a power analysis, which highlights the lack of statistical strength in the resulting conclusions., Results: The results of the initial work state that an advantage exists in treating patients within 48 hours in comparison to treating them during a period greater than 48 hours after the onset of CES symptoms. However, the authors also state that no difference exists between the effects of an early surgery (less than 24 hours) compared with a subsequent period between 24 and 48 hours after CES onset. Key elements of logistic regression and meta-analysis are used to refute specific aspects of their methodology as well as their clinical interpretation regarding acute intervention., Conclusions: We conclude that a flawed methodology and misinterpretation of results are reported, understating the value of early surgical intervention.

The authors report a rare case of type-1 Gaucher disease with neurological and haematological involvement. The first onset was epilepsy, the diagnosis of GD1 was then confirmed and the patient experienced parkinsonism. The biological analysis revealed monoclonal gammapathy and factor-II mutation. The patient's condition worsened due to cauda equina syndrome. Magnetic resonance imaging and surgery revealed an intra-thecal sacral cyst which, to our knowledge, has not been reported previously; therefore, when confronted with the fractures commonly observed in GD1, other unusual causes of spinal cord and root compression should not be overlooked.

We describe a case of cauda equina syndrome caused by synovial cysts and the lithotomy position. A transurethral resection of the prostate was performed under spinal anesthesia in the lithotomy position. We believe that this is the first case report of facet joint synovial cysts and the lithotomy position causing ischemic neurologic injury to the cauda equina. Other etiologies such as needle trauma, neurotoxicity, hematoma, and abscess were not evident. We believe that positioning the patient in the lithotomy position narrowed the cross-sectional area of the spinal canal in a patient with a coexisting critically stenosed lumbar spinal canal. The resultant mechanical pressure caused an ischemic compression injury to the cauda equina.

A retrospective review of all patients who had surgery for cauda equina syndrome (CES) due to a herniated lumbar disc between January 1996 and November 1999 was undertaken. All underwent laminectomy and discectomy, and had been admitted as emergencies with cauda equina syndrome. Ten women and 10 men with a mean age of 45 years (range 33-67) had their diagnosis verified with MRI in 19 cases and CT in one case. Only half the patients had been catheterized at the time of admission to the neurosurgical unit. Nine patients had emergency decompressive surgery within 5 h of presentation to our unit. The others had surgery on the next available list, but within 24 h of admission. No difference was found between urgently operated patients and those operated on the next available list when urological outcome and quality of life assessments were made using a validated questionnaire at a mean time of 16 months after surgery (range10-48). Twenty per cent of a control group who had undergone laminectomy and discectomy for large disc herniations, but without CES had new urological symptoms when questioned postoperatively, but similar quality of life status. Emergency decompressive surgery did no significantly improve outcome in CBS compared with a delayed approach.

Study Design: The gait of patients with neurogenic intermittent claudication was analyzed before and after surgery using a ground reaction force plate., Objectives: To analyze the gait characteristics of patients with neurogenic intermittent claudication, to evaluate quantitatively their gait improvement after surgical treatment, and to examine the differences in gait characteristics and postoperative improvement among different types of neuropathy., Summary of Background Data: A number of reports have been published on the pathophysiology or treatment of neurogenic intermittent claudication. However, almost no detailed reports exist on the gait abnormalities associated with this condition., Methods: The subjects were 60 lumbar canal stenosis patients with intermittent claudication who underwent surgery at the authors' hospital. A ground reaction force plate was used for the analysis, and factors related to time and distance (speed, stride, interval, and pitch) were analyzed, as well as factors related to the style of walking (symmetry, reappearance, smoothness, sway, rhythm, and impact)., Results: Before surgery, there were abnormalities of various factors related to the style of walking soon after the patients began to walk. Gait analysis also showed that the pattern of gait abnormality and its improvement after surgery varied depending on the type of neuropathy., Conclusions: Gait analysis permits objective and quantitative evaluation of the gait characteristics of patients with lumbar canal stenosis and is useful for evaluating responses to surgical treatment in these patients.

The authors describe a case of arachnoiditis ossificans (AO) of the cauda equina. The lesion is a rare pathological entity usually confined to the thoracic and high lumbar regions that can cause progressive spinal cord and cauda equina compression, inducing severe neurological deterioration. The authors analyze the clinical symptoms, radiological features, histological data, and treatment options relating to this case and 13 others described in the literature; additionally, they consider the possible mechanisms responsible for ossification of the leptomeninges. Although clustered arachnoidal cells are usually implicated in its pathogenesis, an environment induced by arachnoiditis and disturbed cerebrospinal fluid flow appears to be a more important factor. A therapeutic strategy is proposed for AO for which no effective treatment currently exists.

This 7-year-old boy with Dejerine-Sottas syndrome caused by a mutation in the myelin protein zero gene began to suffer rapid deterioration with increasing leg weakness, loss of the ability to ambulate, and bowel and bladder incontinence. Magnetic resonance imaging of the spine revealed nerve root hypertrophy resulting in compression of the conus medullaris and cauda equina. Decompressive surgery was successful in reversing some of his deficits.

The role of urgent surgery in improving the outcome of cauda equina compression following lumbar central disc prolapse remains controversial. Some series claim improved outcome from emergency decompression whilst others have found no benefit. Resolution of this issue is important because the opportunity to reverse neurological impairment may already have been lost by the time of hospital admission. Removal of a large central disc prolapse can be considerably more difficult than routine discectomy, and may require an extensive exposure. When performed under less than optimal conditions, as often exists in the emergency setting, surgery may even add to rather than alleviate morbidity. This article reviews the pathophysiology of cauda equina syndrome, its definition, and the controversies surrounding management. Where urinary retention with overflow incontinence extists at presentation we believe that urgent decompression confers no benefit.

In cases of acute or progressive development in a few hours of bilateral sciatica, severe foot and occasional quadriceps weakness and/or retention or incontinence of urine with perineal hypalgesia or anesthesia, acute compression of the cauda equina should be suspected, which is usually due to a lumbar disc herniation. Cauda equina syndrome requires emergency spinal surgery. To identify and confirm this syndrome by MR, Ismanoatory. Early surgical decompression must be achieved. Decompression within 24-48 hours significantly improves the neurological and urological outcome. We present the case of a patient who had previously been treated for low back pain who developed a cauda equina syndrome a few days later.

This retrospective study analyzes the mid-term results of 22 patients who underwent diskectomy following a diagnosis of cauda equina syndrome due to prolapsed intervertebral lumbar disks (mean follow-up: 3 years and 9 months). Postoperatively, 17 of 22 patients had complete urinary function recovery within the follow-up period, 4 patients had a persistent stress incontinence, and 1 patient, incontinent 4 years postoperatively, required catheterization. Thirteen of 17 patients had recovery of motor deficits, 14 of 21 of sensory deficits, and 13 of 15 patients regained perianal sensation. There was no statistically significant difference concerning the time between onset of symptoms and surgical decompression and subsequent outcome. Complete evaluation must include imaging and urodynamic investigations. After an accurate diagnosis and adequate operative treatment, postoperative results of cauda equina syndrome appear satisfactory.

Background: Osteochondroma of the spine is a rare condition. We report a case of a patient with a cervical osteochondroma presenting with a polyneuropathy and polyradiculitis simultaneously., Case Description: In a liver-transplant patient with progressive neurological deficits a polyneuropathy and a polyradiculitis were diagnosed. Eventually the patient became quadraparetic and an osteochondroma compressing the cervical spinal cord was found. The patient's neurological symptoms markedly improved after gross total tumor resection and antibiotic therapy., Conclusions: Review of the literature reveals this case to be an unusual presentation of a cervical osteochondroma, its diagnosis being delayed because of concomitant neurological diseases.

Objectives: Paraplegia remains a frequent complication of thoracoabdominal aortic aneurysm (TAAA) repair. Many adjunct therapies have been developed to address this complication. Lumbar drainage is frequently used in an attempt to decrease intrathecal pressure and improve intramedullary perfusion pressure. The effectiveness of this therapy is unclear, and the complications of lumbar drainage used for this indication are unknown. We present a case of intraspinal hematoma with significant neurologic deficit after TAAA repair and review the associated complications of lumbar drains placed for TAAA., Methods: The charts of all patients undergoing operations for TAAA repair were reviewed. Patients who underwent perioperative placement of a lumbar drain were included regardless of aneurysm type or etiology. Demographics, Crawford grade, and perioperative parameters and complications were reviewed., Results: Sixty-five patients underwent TAAA repair with 62 (95%) receiving a preoperative lumbar drain. There were two (3.2%) intraspinal hemorrhagic complications, including one patient with a poor neurologic outcome. No infections or other complications directly related to drainage were identified. Multivariate logistic regression analysis failed to demonstrate a significant association between lumbar drain complications and perioperative and intraoperative parameters such as blood loss or hypotension, level of drain placement, and Crawford grade., Conclusions: Lumbar drainage is a frequent adjunct to TAAA repair. However, placement of the drain itself can be associated with significant complications whose aggravating factors may be unidentifiable. Complications resulting from lumbar drainage should be considered in any patient who has postoperative lower extremity neurologic deficits.

Spinal arachnoid cysts are a relatively uncommon lesion that may be either intra- or extradural, and intradural spinal arachnoid cysts are even less common. These cysts are usually asymptomatic but may produce symptoms by compressing the spinal cord or nerve roots suddenly or progressively. We present three cases in the pediatric age group with spinal intradural arachnoid cysts without a preceding history of trauma. Three patients with symptomatic intradural arachnoid cysts were investigated with conventional T1- and T2-weighted magnetic resonance imaging (MRI). The MRI scans demonstrated the intradural arachnoid cysts with slightly lower CSF signal intensity on the gradient echo images and slightly higher signal intensity on T1-weighted images. The first cyst was located at the level T12-L1 and compressed the conus medullaris, with neurogenic bladder and cauda equina syndrome for 2 months. The second was located at the level C5-T1 ventrally, with spastic gait and neurogenic bladder for 4 years. The other was located at T2-3 ventrally, with sudden onset of quadriplegia after jumping rope. The combined treatment of total resection and wide fenestration in our three patients produced an excellent return of neurologic function in each one, except for residual urinary disturbance in case 2. Intradural spinal arachnoid cysts appear to result from an alteration of the arachnoid trabeculae; some such cysts are ascribed anecdotally to previous trauma or arachnoiditis, whereas the majority are idiopathic and congenital. The majority of intradural spinal arachnoid cysts occur in the thoracic region and most are dorsal to the neural elements. Only 10 cases have been reported in which the intradural arachnoid cysts were located anterior to the cervical spinal cord, of which 8 were in the pediatric age group, like our case 2. Myelography, postcontrast CT myelography and MRI have been demonstrated as useful for the diagnosis of intradural arachnoid cysts. MRI is the imaging modality of choice, and the extent, size and nature of the lesion in our cases were well demonstrated by MRI. Surgical treatment is necessary if progressive neurological dysfunction appears in the course of spinal cord compression. Complete surgical excision of the cysts is the best choice of treatment, and wide fenestration and shunting of the cyst to the peritoneum, pleural cavity or right atrium were the modalities of choice. MRI offers a noninvasive and effective means to make the diagnosis of arachnoid cysts easier. Intradural arachnoid cysts may cause progressive myelopathy; however, the postoperative prognosis is good if the operation is performed prior to neurologic deficits., (Copyright 2001 S. Karger AG, Basel)

The cauda equina syndrome in ankylosing spondylitis (the CES-AS syndrome) is marked by slow, insidious progression and a high incidence of dural ectasia in the lumbosacral spine. A high index of suspicion for this problem must be maintained when evaluating the patient with ankylosing spondylitis with a history of incontinence and neurologic deficit on examination. There has been disagreement in the literature as to whether surgical treatment is warranted for this condition. A meta-analysis was thus performed comparing outcomes with treatment regimens. Our results suggest that leaving these patients untreated or treating with steroids alone is inappropriate. Nonsteroidal antiinflammatory drugs may improve back pain but do not improve neurologic deficit. Surgical treatment of the dural ectasia, either by lumboperitoneal shunting or laminectomy, may improve neurologic dysfunction or halt the progression of neurologic deficit.

Objective: The authors report the late outcome of 104 consecutive patients after Williams' sequestrectomy for virgin lumbar disc herniation., Methods: The clinical records and the mailed questionnaires of 38 women and 66 men operated consecutively between March 1991 and November 1993 were analyzed retrospectively. In these 104 patients, 105 Williams' sequestrectomies were performed., Results: The mean age at operation was 50.5 years (range, 23.2-86.7 yr), and follow-up ranged from 4.1 to 6.9 years (mean, 5.3 yr). Success rates, including excellent, good, and fair results, were 92.5%, 94.7%, and 93.3% for lumbalgia, radicular pain, and neurological dysfunction, respectively. Only a few patients did not improve or presented with worsened symptoms. Three of four patients with cauda equina syndrome recovered immediately after the intervention. There were eight (7.7%) minor postoperative complications, which were treated conservatively. Three women and three men (5.8%) underwent a revision procedure for a recurrent lumbar disc herniation at the same level after 0.4 to 3.1 years (mean, 1.8 yr). Two (1.9%) of these patients underwent further operations because of reherniation, and they required internal instrumentation eventually because of failed back surgery syndrome., Conclusion: Williams' conservative approach with sequestrectomy alone is a safe operative modality. It should be used whenever possible. As demonstrated in our series with a long follow-up time, the results are as favorable as or better than results after standard microsurgical lumbar discectomy with curettement of the interspace. Whether the incidence of failed back surgery syndrome can be reduced by this approach remains to be proved.

Spinal stenosis mainly is a disease of the elderly patient. Mostly the lumbar spine is affected. The assessment is based on the typical constellation of symptoms (neurogenic claudication, subjective weakness) and physical findings (abnormal reflex status, loss of strength, sensory deficits). It further is supported by the radiographic proof of stenosis of the spinal canal, the lateral recess and the intervertebral foramina. The targets of physical therapy are the relief of pain and an improvement concerning the activities of daily living, which are especially impaired by reduced walking distance and difficulties in climbing stairs as well. That can be achieved by physiotherapy treatment of myofascial disorders oral medication/local injection.

Objective: To demonstrate the importance of clinical examination and continued vigilance for neurologic deterioration in patients with sciatica. Cauda equina syndrome, a rare sequela of sciatica, is considered a medical emergency requiring surgical decompression., Clinical Features: A 32-year-old woman had sciatica that rapidly progressed to cauda equina syndrome. Magnetic resonance imaging revealed the presence of a large nonsequestered disk fragment in the lower lumbar spine., Intervention and Outcome: The disk fragment was surgically excised. The patient experienced immediate pain relief after surgery but retained neurologic deficits. After 6 months of rehabilitation, neurologic integrity was restored, aside from patchy sensory loss of the left foot and buttocks. At the 6-month follow-up, the patient's sciatica had not returned., Conclusions: Most cases of sciatica, regardless of cause, will self-resolve; as a result, there might be a tendency to maintain a low index of suspicion for serious, progressive disorders such as cauda equina syndrome. Patients need to be educated as to signs of this emergency condition and informed as to the possible consequences of delaying treatment. By maintaining a high index of suspicion for any case that fails to respond as expected to a course of conservative therapy or that demonstrates signs of cauda equina syndrome, chiropractors can assume a pivotal role by investigating and referring appropriately and by aiding in active rehabilitation postoperatively.

All 38 patients listed for day-case spinal endoscopy over a 12-month period (April 1998 - April 1999), who had chronic severe low back pain with a radiculopathic element, were studied prospectively. The mean [range] pain duration before treatment was 10.9 [2-26] years and 50% had failed back surgery syndrome. In all patients in whom treatment was completed (n = 34), the pain-generating nerve roots were located through symptom interaction with the patient. All had epidural scar tissue, 14 (41%) having dense adhesions. Mobilisation of adhesions around the nerve root (neuroplasty) was performed so that a pocket was formed for the subsequent placement of bupivacaine, Depomedrone and clonidine. No intra-operative complications occurred and side-effects were minimal. Follow-up over a 12-month period showed statistically significant reductions in pain scores and disability. Spinal endoscopy may be the diagnostic method of choice for epidural fibrosis. It has substantial therapeutic and research potential. Prospective randomised studies are required.

According to the literature estimations, 10-25% of patients with spinal cord and cauda equina injuries eventually develop refractory pain. Due to the fact that most classical neurosurgical methods are considered of little or no efficacy in controlling this type of pain, the authors had recourse to microsurgery in the dorsal root entry zone (DREZ). This article reports on the long-term results of the microsurgical approach to the dorsal root entry zone (DREZotomy) in a series of 44 patients suffering from unbearable neuropathic pain secondary to spine injury. The follow-up ranged from 1 to 20 years (6 years on average). The series includes 25 cases with conus medullaris, 12 with thoracic cord, four with cauda equina and three with cervical cord injuries. Surgery was performed in 37 cases at the pathological spinal cord levels that corresponded to the territory of the so-called 'segmental pain', and in seven cases, on the spinal cord levels below the lesion for 'infralesional pain' syndromes. The post-operative analgesic effect was considered to be 'good' when a patient's estimation of pain relief exceeded 75%, 'fair' if pain was reduced by 25-75%, and 'poor' when the residual pain was more than 75% of preoperative estimations. Immediate pain relief was obtained in 70% of patients and was long-lasting in 60% of the total series. The results varied essentially according to the distribution of pain. Good long-term results were obtained in 68% of the patients who had a segmental pain distribution, compared with 0% in patients with predominant infralesional pain. Regarding pain characteristics, a good result was obtained in 88% of the cases with predominantly paroxysmal pain, compared with 26% with continuous pain. There were no perioperative mortalities. Morbidity included cerebrospinal fluid leak (three patients), wound infection (two patients), subcutaneous hematoma (one patient) and bacteremia (in one patient). The above data justify the inclusion of DREZ-lesioning surgery in the neurosurgical armamentarium for treating 'segmental' pain due to spinal cord injuries.

Low back pain affects a minority of individuals over 65 years of age. Four years after the onset of sciatica, the number of individuals working is independent of their workers' compensation status. A complex interaction of metalloproteinases, cytokines, chondrocytes, and macrophages are necessary for the resorption of herniated intervertebral discs. Positional magnetic resonance imaging in the seated extended posture identifies foraminal narrowing that is not visualized with conventional magnetic resonance studies. Compression associated with cauda equina syndrome must be reversed within 48 hours to preserve neurologic function. The gene for transforming growth factor can be transferred to intervertebral discs, resulting in increased proteogylcan production in a rabbit animal model. An aerobic exercise program is as effective as more expensive exercise programs in the treatment of chronic low back pain. Complementary therapies, willow bark and magnets, have marginal benefit for low back pain. Surgical intervention results in improved function for spinal stenosis patients.

Study Design: The case reports of three pregnant patients with lumbar disc herniation causing cauda equina syndrome or severe neurologic deficits are presented to illustrate that disc surgery during gestation is a safe method of management., Objective: To emphasize the importance of recognizing and definitively treating lumbar disc displacement causing neurologic deficits during pregnancy., Summary of Background Data: The advent of magnetic resonance imaging and modern surgical techniques for treatment of lumbar disc displacement allows safe management of this condition at any stage of gestation. A review of the literature on the risks of nonobstetric surgery and the risks of delaying disc surgery until delivery shows that operating at any stage during gestation for severe neurologic deficit secondary to lumbar disc displacement is justified., Methods: A review of the literature on the use of magnetic resonance imaging scan and nonobstetric surgery during pregnancy was performed. Three case reports of the authors' patients who had lumbar disc displacement with cauda equina syndrome or severe neurologic deficit are presented. Patients were placed prone on a four-poster frame, and an epidural anesthetic agent was administered. A one-level hemilaminectomy, partial facetectomy, and disc excision were performed in all three cases., Results: The methods used for diagnosis and surgical treatment of three patients with disc herniation during pregnancy resulted in a satisfactory outcome for both mother and child. The medical literature supports surgical intervention in pregnant patients with cauda equina syndrome and severe and/or progressive neurologic deficit(s) from lumbar disc displacement at any state of gestation., Conclusion: Although extremely rare, cauda equina syndrome and severe and/or progressive neurologic deficit caused by lumbar disc displacement can occur during pregnancy. The prevalence of symptomatic lumbar disc herniation during pregnancy may be on the increase because of the increasing age of patients who are becoming pregnant. These cases showed, and the literature confirms, that pregnancy at any stage is no contraindication to magnetic resonance imaging scan, epidural and/or general anesthesia, and surgical disc excision.

Study Design: Three cases of idiopathic epidural lipomatosis are reported., Objectives: Description of the relationship between spinal pathologic overgrowth of fat tissue and neurologic symptoms., Summary of Background Data: Idiopathic epidural lipomatosis is a very rare condition; it is usually secondary to chronic steroid therapy or endocrinopathic diseases., Methods: Three men with a mean age of 58.5 years, who experienced intermittent claudication, bilateral radicular pain in both legs, and urinary dysfunction with hypoesthesia in the perineal region, were evaluated by plain radiography and magnetic resonance imaging, the results of which demonstrated a pathologic overgrowth of fat tissue in the spinal canal with a marked impingement of the dural sac. Obesity, endocrinopathic diseases, and chronic steroid therapy were excluded for all patients. Surgical treatment was performed by wide multilevel laminectomies, fat debulking, and instrumented posterolateral fusion., Results: After surgery there was a gradual improvement in symptoms and signs so that 2 years later the patients returned to daily activities and were neurologically normal., Conclusions: Spinal epidural lipomatosis can be a cause of back pain but rarely radicular impingement. Magnetic resonance imaging is the procedure of choice. The treatment must be performed early by wide surgical decompression.

Due to the anatomical situation, intervertebral disc herniation usually results in compression of the anterior epidural space, with lateral or medial irritation of nerve root or cauda equina. Rare locations are an intra- or extraforaminal position or dislocation dorsally. Three patients with dorsal cauda equina compression caused by a sequestered herniated nucleus pulposus (HNP) are reported. The patients complained mainly of severe back pain. In two patients nondermatome-related leg pain was observed; one patient suffered additionally from incomplete cauda equina syndrome. In all cases magnetic resonance imaging and computed tomography diagnosed neoplastic tissue.

Gas production as a part of disk degeneration can occur, but it rarely causes clinical nerve compression syndromes. A rare case of gaseous degeneration in a prolapsed lumbar intervertebral disk causing acute cauda equina syndrome is described. Radiologic features and intraoperative findings are reported. A 78-year-old woman with severe lumbar canal stenosis had acute cauda equina syndrome. Magnetic resonance imaging revealed a large disk protrusion, and she underwent an urgent operation for this. Surgery confirmed the severe lumbar canal stenosis, but the disk prolapse contained gas that had caused the nerve compression.

Objective and Importance: Complications usually occur when they are least expected. We present an unusual case of nerve entrapment after microsurgical discectomy., Clinical Presentation: A patient undergoing uneventful first lumbar microsurgical discectomy developed severe back and leg pain and a progressive neurological deficit during the first postoperative night. Herniation of cauda equina nerve roots had occurred through an unnoticed minimal defect in the dura, which had not caused cerebrospinal fluid leakage. The roots were incarcerated and swollen, and they filled the space of the resected nucleus pulposus. It was presumed that elevation of intra-abdominal pressure and consequent increased intraspinal pressure during extubation led to the herniation of arachnoid and cauda equina roots. The nerve roots were then trapped and incarcerated in the manner of bowel loops in an abdominal wall hernia., Intervention: During reoperation, the nerve roots were repositioned into the dural sac. The patient recovered without further complications and without long-term sequelae., Conclusion: All dural tears that occur during intraspinal surgery, even if they are small and the arachnoid is intact, should be closed with stitches or at a minimum with a patch of muscle or gelatin sponge with fibrin glue. Care should be taken to avoid increased intra-abdominal pressure during extubation. Excessive pain and progressive neurological dysfunction occurring shortly after microsurgical lumbar discectomy or any intraspinal procedure is indicative of possible hemorrhage with subsequent compression of nerve roots. The case reported here provides anecdotal evidence that this situation can also be caused by a herniation of cauda equina nerve roots through a small dural defect that was not evident during the initial operation.

We describe the case of an acute cauda equina syndrome secondary to a confined subarachnoid bleed from a spinal arteriovenous malformation. The patient was elderly and made a complete neurological recovery following surgery.

The anterior decompressive procedure in which spinal fusion is performed is considered an effective treatment for thoracolumbar fractures and tumors. However, it is also known to be associated with considerable surgery-related trauma. The purpose of this study was to show that lumbar corpectomy and anterior reconstruction can be performed via a minimally invasive retroperitoneal approach (MIRA) and therefore the surgical approach-related trauma can be reduced. The authors studied retrospectively the hospital records and radiological studies obtained in five patients (mean age 67.4 years, range 59-76 years) who underwent lumbar corpectomy and spinal fusion via an MIRA followed by posterior fixation. Four patients presented with osteoporotic compression fractures at L-2 and L-3, and one patient presented with metastatic disease in L-4 from prostate cancer. Neurological deficits due to cauda equina compression were demonstrated in all patients. The MIRA provided excellent exposure to facilitate complete decompression and anterior reconstruction in all patients, as verified on follow-up radiographic studies. All patients improved clinically. A 1-year follow-up record is available for four patients and a 6-month follow-up record for the fifth patient; continuing clinical improvement has been observed in all. Radiography demonstrated anatomically correct reconstruction in all patients, as well as a solid fusion or a stable compound union in the four patients for whom 1-year follow-up records were available. The MIRA allows the surgeon to perform anterior lumbar spine surgery via a less invasive approach. The efficacy and safety of this technique and its potential to reduce perioperative morbidity compared with conventional retroperitoneal lumbar spine surgery should be further investigated in a larger series.

Study Design: A meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation., Objectives: To determine the relationship between time to decompression after onset of cauda equina syndrome and clinical outcome, and to identify preoperative variables that were associated with outcomes., Summary of Background Data: The timing of surgical decompression for cauda equina syndrome is controversial. Although most surgeons recommend emergent decompression, results in certain studies show that delayed surgery may provide a satisfactory outcome., Methods: A meta-analysis was performed to determine the correlation between timing of decompression and clinical outcome. One hundred four citations were reviewed, and 42 met the inclusion criteria. Preoperative and postoperative data were recorded. Length of time to surgery was broken down into five groups: less than 24 hours, 24-48 hours, 2-10 days, 11 days to 1 month, and more than 1 month. Logistic regression was used to determine the association between preoperative variables and postoperative outcomes., Results: Outcomes were analyzed in 322 patients. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No significant improvement in surgical outcome was identified with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24-48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Significant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms., Conclusions: There was a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of cauda equina syndrome. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.

Study Design: An analysis of 44 cauda equina syndrome cases., Objectives: To determine the neurologic outcome of cauda equina syndrome cases, in light of the significant medical implications of this disorder., Summary of Background Data: Cauda equina syndrome from lumbar disc herniation accounts for up to 1% of all disc herniations. Most of the literature supports surgery within 24 hours as a means of improving the outcome., Methods: A retrospective chi 2 analysis was performed of 44 patients surgically treated for lumbar disc herniation who initially sought treatment for cauda equina syndrome., Results: In 20 patients, diagnosis was made and surgery performed within 48 hours of the cauda equina syndrome onset, including 18 patients (90%) who underwent surgery within 24 hours. In 24 patients, surgery was performed more than 48 hours after the onset of cauda equina syndrome, with a mean delay of 9 days, including 17 patients (71%) with a mean delay of 3.7 days. Causes for delay were patient-related in 4 cases (17%) and physician-related in 20 cases (83%). According to chi 2 analysis, a greater chance of persistent bladder/sphincter problem (P = 0.008), persistent severe motor deficit (P = 0.006), persistent pain (P = 0.025), and sexual dysfunction (P = 0.006) existed with delayed surgery., Conclusion: The data strongly support the management of cauda equina syndrome from lumbar disc herniation as a diagnostic and surgical emergency.