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Figure A
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Figure B
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Figure C
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Figure D
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Figure E
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Figure E is a normal appearing MRI of the spine with no obvious reason for a cauda equina syndrome. Cauda Equina Syndrome (CES) is caused by severe compression of the nerve roots in the thecal sac of the lumbar spine, most commonly due to an acute lumbar disc herniation. Early diagnosis is critical and is made clinically by characteristic symptoms of saddle-like paresthesias combined with acute back and leg pain. Urgent MRI is performed to confirm the cause. Treatment is prompt surgical decompression that should preferably be performed within 24 hours, absolutely within 48 hours. Spector et al. reviewed cauda equina syndrome. They reported that the syndrome is characterized by varying patterns of low back pain, sciatica, lower extremity sensorimotor loss, and bowel and bladder dysfunction. They noted that classically, the full-blown syndrome includes urinary retention, saddle anesthesia of the perineum, bilateral lower extremity pain, numbness, and weakness. Decreased rectal tone may be a relatively late finding. They concluded that a high index of suspicion is necessary in the postoperative spine patient with back and/or leg pain refractory to analgesia, especially in the setting of urinary retention. Regardless of the setting, when cauda equina syndrome is diagnosed, the treatment is urgent surgical decompression of the spinal canal. Gitelman et al. reviewed cauda equina syndrome. They reported that is a rare syndrome that has been described as a complex of symptoms and signs including low back pain, unilateral or bilateral sciatica, motor weakness of lower extremities, sensory disturbance in saddle area, and loss of visceral function. They concluded that CES occurs in approximately 2% of cases of herniated lumbar discs and is one of the few spinal surgical emergencies. Figures A-D are lumbar MRI of patients that developed cauda equina syndrome, with each image showing focal pathology. Figure E is a normal lumbar MRI. Incorrect Answers: Answer 1: Figure A is an MRI of the spine revealing a burst fracture. Answer 2: Figure B is an MRI of the spine revealing a large lumbar disc bulge. Answer 3: Figure C is a MRI of the spine revealing prostate metastases to the sacrum. Answer 4: Figure D is a MRI of the spine revealing extension of the soft tissue mass into the spinal canal secondary to spinal lymphoma.
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