MRI of the spinal cord
MRI of the spinal cord
A 65-year-old woman presents to the emergency department with acute chronic back pain and lower extremity weakness. She has also had loss of bladder control during the last 8 hours. Sagittal MRI images (Figures 1 and 2) show anterolisthesis of T11 on T12 resulting in severe canal stenosis and kinking of the spinal cord. There is hyperintense signal in the spinal cord at the thoracic level reflecting spondylotic myelopathy versus myelomacia.
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The patient’s MRI and clinical presentation are suggestive of cauda equina syndrome (CES). Pain in the back, buttock, and lower extremities, saddle anesthesia, and loss of bowel and bladder function are classic findings. Urinary retention or incontinence are often found in early CES, with retention generally preceding incontinence. Physical exam findings may vary depending on the severity of CES. A careful rectal exam helps make the diagnosis, as poor anal sphincter tone is a characteristic finding.1,2
The most devastating consequences of CES can be permanent loss of bowel, bladder, and sexual function. Patients presenting with CES should be treated with an urgent surgical decompression within 48 hours of symptom onset. Patients treated within 48 hours of onset of symptoms were found to have improved sensory and motor recovery as well as urinary and rectal function compared with those treated after 48 hours. There is no difference in neurologic recovery between patients treated within 24 hours and those treated within 48 hours. Neurologic recovery generally occurs during the 4-month to 13-month postoperative period, although improvements have been seen up to 2 to 3 years. Urinary incontinence and loss of bowel control are more likely to improve than sexual dysfunction. Perianal numbness is generally the last deficit to recover and the most likely to persist permanently. Chronic back pain, pre-operative rectal dysfunction, and increasing age are poor prognostic indicators for clinical improvement postoperatively.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Dhatt S, Tahasildar N, Tripathy SK, Bahadur R, Dhillon M. Outcome of spinal decompression in cauda equina syndrome presenting late in developing countries: case series of 50 cases. Eur Spine J. 2011;20:2235-2239.
- Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine (Phila Pa 1976). 2000;25:1515-1522.