Clarification of Answer by
29 Aug 2004 20:48 PDT
In response to your clarification request for additional information
other than what was requested in the original question - I am
presenting more detailed resources for your perusal.
Archives of Neurology
Neurourologic findings in conus medullaris and cauda equina injury
"In extreme cases, lumbar stenosis can cause cauda equina syndrome, a
syndrome characterized by neuromuscular dysfunction, and may result in
permanent nerve damage. Because many studies excluded patients with
cauda equina syndrome, we were not able to consider evidence related
to it; and, therefore, consideration of cauda equina syndrome is
beyond the scope of this evidence report. This report, therefore,
focuses on less extreme manifestations of lumbar spinal stenosis and
considers the evidence surrounding all aspects of this condition."
"More severe stenosis can result in cauda equina syndrome. A common
belief is that untreated spinal stenosis can result in severe symptoms
and may become permanent and unresponsive to medical or surgical
treatment. However, except for acute onset of symptoms seen among
patients with herniated disks, none of the studies that met our
inclusion criteria examined how often these consequences occur among
patients with lumbar spinal stenosis."
Spinal Endoscopy - Mark S. Gorchesky, M.D., DABPM
Mark S. Gorchesky, M.D., DABPM is with the Center for
Pain Management at University Medical Center, Jacksonville.
1931 - The first documented peer reviewed article on spinal canal
endoscopy by Dr. Michael Burman. Eleven cadaver vertebral columns were
examined using arthroscopic equipment (trochar with 3/8 inch), he
concluded that myeloscopy was limited due to current technology but
potential merit included visualization of the cauda equina for tumor
(reference: Burman MS. Myeloscopy or the Direct Visualization of the
Spinal Canal and its Contents, Journal of Bone and Joint Surgery,
1937 - Dr. J. Lawrence Pool performed his first myeloscopic exam on an
anesthetized subject. Late in 1942 he published experience with 400
cases, most performed with local anesthesia in the sitting position.
His equipment was cumbersome but it allowed CSF sampling, manometric
measurements and gas myelography through the myeloscope. Hand drawings
and observations revealed normal anatomic relationships, epidural fat,
neuritis of the filum terminilie and effects of a herniated nucleus
pulposus or hypertrophied ligamentum flavum, arachnoid adhesions and
unilateral neuroepithelioma of the cauda equina.
(reference: Pool JL, Bull. Direct Visualization of Dorsal Nerve Roots
of Cauda Equina by Means of a Myeloscope. Archives of Neurology and
Psychiatry. 1938; 39:1308-1312)
1981 - Ooi, et al report observations in changes in blood flow in the
cauda equina during the Lasegue test. During the straight leg raising
maneuver the author noted an anterior caudal displacement of the cauda
equina and a cessation of blood flow. Valsalva, coughing or sneezing
only resulted in a slight cephalad/caudad movement in the cauda
(reference: Ooi Y, et al. Myeloscopy with Special Reference to Blood
Flow Changes in the Cauda Equina During Lasegue's Test. Internation
Orthopedics. 1981; 4:307-311)
Clinical Evaluation and Treatment Options for Herniated Lumbar Disc
S. CRAIG HUMPHREYS, M.D., and JASON C. ECK, M.S.
"Initial screening for serious pathology and monitoring for the
development of significant complications (such as neurologic defects,
cauda equina syndrome or refractory pain) are essential in the
management of lumbar disc herniation."
"A central herniated disc may also compress nerve roots of the cauda
equina, resulting in difficult urination, incontinence or impotence.
The medical history and physical examination may disclose bowel or
bladder dysfunction. In such cases, immediate referral to a specialist
is required for emergency surgery to prevent permanent loss of
'Red Flags' in the Medical History: Potentially Serious Conditions
That May Present as Low Back Pain
Cauda equina syndrome
* Saddle anesthesia
* Recent onset of bladder dysfunction
* Severe or progressive neurologic deficit in lower extremity
Possible cauda equina syndrome can be identified by unexpected laxity
of the anal sphincter, perianal or perineal sensory loss, or major
motor loss in the lower extremities."
Surgical Indications for Herniated Disc
"While most patients with a herniated disc may be effectively treated
conservatively, some do not respond to conservative treatment or have
symptoms that necessitate referral to a specialist. Any surgical
decisions should be firmly based on the clinical symptoms and
corroborating results of diagnostic testing. Indications for referral
include the following: (1) cauda equina syndrome..."
Cauda Equina Syndrome - Medifocus Guide - Item # XL538
*I'm not able to pay for the articles, however if you are interested -
here is the link for Pricing And Ordering Information:
1. Microsurgical DREZotomy for pain due to spinal cord and/or cauda
equina injuries: long-term results in a series of 44 patients. - Pain.
2. Lumbar pannus presenting as cauda equina syndrome in a patient
with longstanding rheumatoid arthritis. - Journal of Rheumatology.
3. Surgery for lumbar disc herniation during pregnancy. - Spine. 2001
4. Cauda equina syndrome secondary to idiopathic spinal epidural
lipomatosis. - Spine. 2001
5. Cauda equina syndrome as a postoperative complication in five
patients operated for lumbar disc herniation. - Spine. 2001
6. The earliest case of cauda equina syndrome caused by manipulation
of the lumbar spine under a general anaesthetic. - Spinal Cord. 2001
Featured Article from this Guide
Article: Predictors of outcome in cauda equina syndrome.
Author: Kennedy JG. Soffe KE. McGrath A. Stephens MM. Walsh MG. McManus F.
Institution: Department of Orthopaedic Surgery, University College
Dublin, Mater Misericordiae Hospital, Ireland.
Journal: European Spine Journal. 8(4)317-22, 1999.
Cauda Equina Syndrome Resulting from Spinal Anesthesia - Medifocus
Guide - Item # XL462
1. Acute cauda equina syndrome after total knee arthroplasty as a
result of epidural anesthesia and spinal stenosis. - Journal of
2. AANA Journal course: transient neurologic symptoms and spinal
anesthesia. - AANA Journal. 2000
3. Potential neurotoxicity of spinal anesthesia with lidocaine. -
Mayo Clinic Proceedings. 2000
4. Complications of spinal and epidural anesthesia. - Anesthesiology
Clinics of North America. 2000
5. Combined spinal-epidural techniques. - Anaesthesia. 2000
6. The combined spinal-epidural technique. - Anesthesiology Clinics
of North America. 2000
7. Neurologic complications of spinal and epidural anesthesia. -
Regional Anesthesia & Pain Medicine. 2000
8. Cauda equina syndrome after incidental total spinal anesthesia
with 2% lidocaine. - Journal of Clinical Anesthesia. 1998
9. Continuous microspinal anaesthesia: another perspective on
mechanisms inducing cauda equina syndrome. - Anaesthesia. 1998
10. Commentary: neurotoxicity of local anesthetics--an issue or a
scapegoat?. - Regional Anesthesia & Pain Medicine. 1998
Pain after Spinal Cord Injury
"Nerve root entrapment pain often begins days to weeks after injury
and may worsen over time. It occurs at or just below the level of
injury and has a distinct pattern. You may feel brief waves of
stabbing or sharp pain or a band of burning pain at the point where
your normal feeling stops. You may find that light touch makes the
pain worse. The pain stems from compression of a nerve root by a bone
or disk. Pain from damage to the cauda equina (the lower part of the
spinal column) is a type of nerve root pain that is described as a
burning feeling in the legs, feet, pelvis, genitals, and rectum."
"Segmental pain may also be eased with neuropathic pain-releaving
medications. Other treatments that may also be effective include
spinal cord stimulation and epidural blocks along with surgical
procedures such as dorsal root entry zone lesions and dorsal
Nerve root entrapment pain stems from vertebral instability. It might
be relieved by stabilization, by opiates or by neuropathic
pain-releaving medications. If there is bone or disk material present,
decompression surgery is usually done to relieve the pain. Treatment
to the peripheral nerves is usually needed to relieve pain from damage
to the cauda equina."
Spinal cord stimulators and spinal pumps for coccyx pain
Spinal Cord Stimulator
Spinal cord stimulators and pain pumps - implantable systems
Transcutaneous electrical nerve stimulation, or TENS unit (also called
electrotherapy), involves placing an external device over the skin
that applies low-voltage electricity via electrodes. Generally, TENS
units are applied for moderate to moderately severe acute to subacute
pain, and for some people they may be effective for chronic pain as
Exercises supervised by a physical therapist and/or occupational
therapist and eventually performed independently may be beneficial to
help rehabilitate weakened muscles and prevent injury, as well as to
develop and maintain flexibility and aerobic conditioning.
Finally, because of the profoundly devastating effect that chronic,
intractable pain can have on all aspects of one?s life - physical,
psychological, emotional - it is often beneficial for patients to
participate in psychological counseling.
Some psychologists specialize in helping patients manage chronic pain
through use of biofeedback, imaging techniques, meditation, and other
methods. Developing useful psychological tools and techniques can help
a patient feel more empowered, with a greater sense of control over
their pain, which can ultimately lead to a better outcome.
Spinal Cord Stimulators
The following Local Medical Review Policy (LMRP) was developed by this
state's Medicare Carrier and DOES NOT represent ASCO policy
"Spinal cord stimulation blocks pain conduction pathway and stimulate
endorphins. The neurostimulator electrodes used for this purpose are
implanted percutaneously in the epidural space through a special
needle. Some patients may need an open procedure requiring laminectomy
to place the electrodes.
After placement of the electrodes, the patient is provided with an
external neurostimulator, initially on a trial basis, the trial period
of one-week (i.e. five days) may be extended up to two weeks. If
during the trial period it is determined that the modality is not
effective or it is not acceptable to the patient, the electrodes may
If the trial has been successful, a spinal neurostimulator and pulse
generator, activated through a radio frequency device, is inserted
subcutaneously and connected to the electrodes already in place."
INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY
9. To treat intractable pain caused by cauda equina injury; and
DORSAL COLUMN STIMULATION
Involves the implantation of an electronic stimulator near the spine
that interrupts the pain signal to the brain.
TENS - Transcutaneous Electrical Nerve Stimulation
ClinicalTrials.gov - Spine Patient Outcomes Research Trial (SPORT): Spinal Stenosis
This study is currently recruiting patients.
Duration of Symptoms: 12 or more weeks.
Treatments tried: Nonsteroidal anti-inflammatory medical therapy and
Surgical Screening: Pain in low back, buttocks, or lower extremity
that becomes worse with lumbar extension. Must be confirmed by
evidence of central or central-lateral compression of the cauda equina
by a degenerative lesion of the facet joint, disc, or ligamentum
flavum on MRI, computed tomography scans, or myelograms.
Tests: MRI to confirm diagnosis and level(s).
Nerve Root Disorders
When the herniated nucleus compresses or irritates the nerve root,
sciatica results. Posterior protrusion can compress the cord or cauda
equina, especially if the spinal canal is congenitally narrow (spinal
"Cervical cord compression may cause spastic paresis of the lower
limbs. Cauda equina compression often results in urine retention or
incontinence from loss of sphincter function; these signs indicate the
need for urgent care.
Diagnosis and Treatment
Treatment should be conservative because most patients with low back
or nerve root pain recover without surgery--up to 95% by 3 mo--unless
they have progressive or severe neurologic deficits. Acute discomfort
may subside with rest and relaxation. Prolonged bed rest is
contraindicated. Analgesics, mild tranquilizers, and muscle relaxants
help relieve pain.
For lumbar radiculopathies, traction usually has no added benefit. If
objective neurologic deficits (weakness, sensory deficit) persist or
worsen or if nerve root pain is severe and intractable, invasive
treatment should be considered. Microscopic diskectomy or laminectomy
or surgical removal of herniated material is usually the procedure of
choice. Percutaneous approaches to remove bulging disk material are
being evaluated. Dissolving herniated disk material with local
injections of the enzyme chymopapain is not recommended. Lesions
acutely compressing the spinal cord or cauda equina (eg, producing
urine retention or incontinence) require immediate surgery."
ARC (ARACHNOIDITIS) NEWSLETTER
Volume 3, No.1 Spring 2003. Published by the ARACHNOIDITIS FOUNDATION, Inc
NEUROLOGIC DEFICITS AND ARACHNOIDITIS FOLOWING NEUROAXIAL ANESTHESIA
Of late, regional anesthesia has enjoyed unprecedented popularity;
this increase in cases has brought a higher frequency of instances of
neurological deficit and arachnoiditis that may appear as transient
nerve root irritation, cauda equina, and conus medullaris syndromes,
and later as radiculitis, clumped nerve roots, fibrosis, scarring,
dural sac deformities, pachymeningitis, pseudomeningocele, and
syringomyelia, etc, all associated with arachnoiditis. Arachnoiditis
may be caused by infections, myelograms (mostly from oil-based dyes),
and blood in the intrathecal space, neuroirritant, neurotoxic and/or
neurolytic substances, surgical interventions in the spine,
intrathecalcorticosteroids, and trauma.
Arachnoiditis Foundation, Inc.P.O. Box 4627, Seaside,
Peer reviewed article Boos N. Akute Myelopathie und Cauda-equina-Syndrom.
Schweiz Med Wochenschr 2000;130:844-50.
Acute myelopathy and cauda equina syndrome
(See right side of article for English translation.)
A Case Study of Cauda Equina Syndrome
In contrast to sciatica, cases of CES after disk herniation are
relatively rare; according to Chang et al, the incidence of CES due to
lumbar disk herniation has been reported to range from 1% to 10% of
operated disk cases.
(reference: Chang HS, Nakagawa H, Mizuno J. Lumbar herniated disc
presenting with cauda equina syndrome. Long-term follow-up of four
cases. Surg Neurol 2000 Feb;53(2):100-4;discussion 105)
Orthopedics: Low Back Pain
David C. Krupp, MD and Mark A. Graber, MD
Peer Review Status: Externally Peer Reviewed by Mosby
Acute back pain (no longer than 6 weeks).
1. There is no difference in outcome when patients with acute back
pain are treated by a family physician, a chiropractor, or an
orthopedic surgeon. Therapy by a family physician is the most cost
2. Regardless of the method of treatment, 40% are better within 1
week, 60% to 85% in 3 weeks, and 90% in 2 months. Negative prognostic
factors include more than 3 episodes of back pain, gradual onset of
symptoms, and prolonged absence from work.
3. Bedrest. Should be kept to a minimum and early mobilization
encouraged. This is true in both back strain and radicular disease. If
symptoms recur or considerable pain develops in relation to a specific
activity or level of activity, the patient should temporarily limit
that activity for several days but should not cease all activity.
4. Analgesia. NSAIDs provide pain relief and decrease inflammation
but have side effects. Acetaminophen provides analgesia but has no
anti-inflammatory properties and may be used with or instead of
NSAIDs. Narcotics should be used short term as needed. Muscle
relaxants such as cyclobenzaprine or diazepam work mostly by sedating
patients and preventing activity. However, they probably have little
effect on muscle spasm.
5. Physical therapy. Although classically several modes have been
used to hasten resolution of back pain, most physical therapy
modalities have no effect when rigorously tested. Traction, local
application of heat, cold, and ultrasound, and corsets have been shown
to have no effect. Proper lifting, strengthening, and weight loss may
prevent recurrence. Transcutaneous electrical nerve stimulation may
provide short-term symptomatic relief but has no proven long-term
benefit. Acupuncture may also be of help.
6. Epidural steroid injections. These have been classically used but
a randomized trial shows that there is no benefit.
7. Rehabilitation exercises. Trunk extensors, abdominal muscles,
aerobic conditioning. The main benefit is that they promote early
mobilization, which is critical in treating acute back pain. The
specific exercise does not matter as much as the mobilization.
8. Back support belts are ineffective in preventing back pain.
Chronic back pain. Once back pain has been established for more than 1
year, the prognosis is poor. Mild analgesia should be used. Avoid
chronic reliance on narcotics if possible (although addiction rates
are low with chronic pain). If depression is encountered, it should be
treated. Other modalities for chronic pain include tricyclics,
carbamazepine and gabapentin. Physical modalities include
transcutaneous electrical nerve stimulation or acupuncture with
electrical stimulation. Both are effective but for a limited duration
C. Indications for admission and referral. Cauda equina syndrome
(urinary retention, sphincter incontinence, saddle anesthesia), severe
neurologic deficits (footdrop, areflexia, gastrocnemius-soleus or
quadri-ceps weakness), progressive neurologic deficit, or multiple
nerve root involvement
Cauda Equina Syndrome
Published by the Journal of Neurosurgery and American Association of
June 2004, Volume 16, Issue 6
1. Spinal epidural hematoma causing acute cauda equina syndrome.
Khaled M. Kebaish and John N. Awad
2. Infectious origins of cauda equina syndrome. David B. Cohen
3. Cauda equina syndrome caused by primary and metastatic neoplasms.
Carlos A. Bagley and Ziya L. Gokaslan
4. Conus medullaris and cauda equina syndrome as a result of traumatic
injuries: management principles. James S. Harrop, Gabriel E. Hunt Jr.,
and Alexander R. Vaccaro
5. Cauda equina syndrome after induction of spinal anesthesia. Serdar
Ozgen, Nigar Baykan, I. Varlik Dogan, Deniz Konya, and M. Necmettin
6. Cauda equina syndrome in patients with low lumbar fractures. Issada
Thongtrangan, Hoang Le, Jon Park, and Daniel H. Kim
7. Cauda equina syndrome as a postoperative complication of lumbar
spine surgery. Randy L. Jensen
8. Medicolegal consequences of cauda equina syndrome: an overview. John P. Kostuik
Cauda equina syndrome from intradiscal electrothermal therapy
Wetzel et al. Neurology.2001; 56: 1607
Purchase Short-Term Access
Pay per Article - You may access this article (from the computer you
are currently using) for 24 hours for US$20.00.
Compression of spinal cord and cauda equina in Charcot-Marie-Tooth disease type...
BŁtefisch et al. Neurology.1999; 52: 890
Cauda Equina and Conus Medullaris Syndromes
Epidural compression of the cauda equina caused by vertebral
osteoblastic metastasis of prostatic carcinoma: resolution by hormonal
59 year old man with prostatic carcinoma developed epidural
compression of the cauda equina caused by bony expansion from a
vertebral osteoblastic metastasis. For medical reasons he could not
undergo radiation or surgery. Hormonal therapy alone relieved his low
back pain and restored ambulation and urinary function.
Postmyelography CT showed that the bony expansion from the vertebra
had completely disappeared after treatment. This is the first report
of remarkable improvement due to hormonal therapy alone.
Unfortunately, as the patient's general condition deteriorated due to
incidental severe pneumonia, he could not undergo surgical
decompression or radiation therapy. Corticosteroids also could not be
used. Hormonal therapy, that combined an antiandrogen (oral
chlormadinone acetate, 100 mg daily) with luteinising
hormone-releasing hormone (LH-RH) analogue (leuprorelin acetate, 3.75
mg subcutaneous injection once every 4 weeks) was started. This
regimen was continued throughout the observation period. His low back
pain and paraesthesia in both legs resolved within 6 weeks. Eight
weeks later, his serum prostate specific antigen dropped to 15 ng/ml.
Follow up myelography and postmyelography spinal CT 11 weeks after the
start of hormonal therapy showed that both the epidural mass in the
body of Th11 and the bony expansion from the body of L2 had
disappeared (figure). By that time, muscle power in his right lower
limb had improved to grade 4-5, and urinary retention had disappeared.
Fifteen weeks later, he was discharged from the hospital and could
walk with the aid of a cane.
Singh H, Rao VS, Mangla R, Laheri VJ. Traumatic transverse fracture of
sacrum with cauda equina injury--a case report and review of
literature. J Postgrad Med 1998;44:14-5
Traumatic transverse fracture of sacrum with cauda equina injury--a
case report and review of literature
Spinal Cord Injury Association - What Reduces Pain
If you are living with pain, there are some psychological approaches
that you can take to help reduce your pain. You can learn to better
cope with stress and overcome depression through professional
counseling, although severe depression may require medication. Some
techniques that you might learn through counseling include a
relaxation training, biofeedback and hypnosis.
The Distraction technique may also help reduce chronic pain. When you
have pain, it may increase when you are not active or you begin to
relax such as before you go to sleep. This increase in pain occurs
because you have time to focus on the pain. When you are participating
in enjoyable and meaningful activities, your awareness of pain
decreases. For example, when you are busy with work, school, or
recreational activities, you are not as likely to focus on your pain.
Pain management can be very important in improving your overall
quality of life. If you are in pain, talk with a doctor. Start first
with the simple methods of reducing your pain. You may have to try
several treatments before finding one, or a combination, that works
for you. Do not treat yourself because you may have a serious health
problem that may be causing the pain. Ultimately, the solution may not
be a cure. You may not be able to live completely pain free. You may
only be able to reduce your pain. But easing the pain may be enough
for you to live a productive, satisfying life.
For additional updated resources on Pain visit the Spinal Cord Injury
Information Network website.
(See links to the following resources)
Chronic Pain after Spinal Cord Injury
Newsletter article from Spinal Cord Injury Update, Summer, 1995 by the
NW Regional SCI System, University of Washington, on types of pain
following a spinal cord injury and treatment strategies,
Chronic Pain in SCI, A New Grant Funds a Study
An article that details a study done to learn more about the
frequency, characteristics, and impact of chronic pain in people with
SCI. From the Summer 1997, Spinal Cord Injury Update newsletter, by
the NW Regional SCI System, University of Washington.
Controlling Central Pain
By: Kenneth McHenry, MD
An article from New Mobility magazine [March, 1998) that explains
central pain, a unique type of pain that individuals with SCI may
experience. It offers suggestions for working with one's doctor to
understand and treat central pain and tells of current research in
Healthy Living: Pain and SCI
A question and answer article from Pushin' On discussing pain and SCI (July, 2002).
Joe's Story: Fighting Pain
Available from: Films for the Humanities & Sciences
PO Box 2053, Princeton, NJ 08543-2053
This video tells the story of one man who choses to have a spinal cord
stimulator implanted to help control pain. A Discovery Channel
Time: 24 minutes
Cost: $129 / Rental: $75
New study may explain spinal cord pain
A new study by Yale researchers has found a possible explanation for
chronic pain in patients with spinal cord injuries.
North American Chronic Pain Association of Canada, NACPAC
60 Lorne Ave
Dartmouth, Nova Scotia B24 3E7
Phone: 902-463-5587 TOLL FREE: 1-866-470-PAIN (7246)
NACPAC is a self-help organization dedicated to providing support to
people in chronic pain, and to giving them assistance in living their
lives to the fullest. This site contains information and links to
resources on medical information, research, and publications.
Pain Management following Spinal Cord Injury
InfoSheet #10, Updated May, 2001
Discusses the types of SCI pain and pain management.
Pain after a Spinal Cord Injury: Predicting, Diagnosing and Treating
Research Review newsletter, Vol 3(1), Spring, 2001.
Reviews current research on pain at the UAB RRTC & Model SCI Center
and its importance in predicting, diagnosing and appropriately
treating pain in individuals with SCI.
PDF format [Evaluate]
Pain following SCI
Discusses the types of SCI pain, treatment methods, and keys to a
successful management program.
Pain in Spinal Cord Injury: Causes and Treatments
An article from the Spinal Cord Injury Update newsletter, Summer,
2001, published by the Northwest Regional SCI System at the University
of Washington School of Medicine. It discusses results of a recent
study at UW and the various types of SCI pain.
A website for both physicians and persons who are experiencing Central
Pain. It gives descriptions of central pain, and encourages those with
central pain to respond with their symptoms.
Research Update: Classification, Treatment and Risk Models of Pain following SCI
An article from Pushin' On reviewing a current research project to
improve pain management after SCI (July, 2002).
Secondary Conditions: Prevention Series
By: Glen White, PhD; John Youngbauer
The Research and Training Center, University of Kansas
4089 Dole Bldg., Lawrence KS 66045-2930
A series of booklets and information sheets on secondary conditions or
complications of SCI, including chronic pain, chronic fatigue,
contractures, pressure sores/skin, aging, and urinary tract infection.
Additional topics are planned.
Cost: $2.50 ea. s/h $2.00 for first 15 booklets and $1.00 for every
additional fifteen booklets ordered.