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Q: cauda equina syndrome ( Answered,   0 Comments )
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Subject: cauda equina syndrome
Category: Health
Asked by: jan58-ga
List Price: $100.00
Posted: 24 Aug 2004 10:17 PDT
Expires: 23 Sep 2004 10:17 PDT
Question ID: 391912
What are the long term effectws of cauda equina syndrome
Answer  
Subject: Re: cauda equina syndrome
Answered By: tlspiegel-ga on 24 Aug 2004 14:01 PDT
 
Hi jan58

Thank you for your interesting question. 

Please note the *Important Disclaimer* at the bottom of this page.  I
am not a health care provider and can only provide general
information.  Always consult a physician for in depth information and
specifics about your concerns.

With that said...


HOW CES AFFECTS PEOPLE: 
http://www.caudaequina.org/definition.html

CES is a devastating condition which can damage many aspects of life.

Often, the sufferer can no longer continue to work, either from severe
pain, or because of loss of muscle power, or due to socially
unacceptable continence problems, or indeed a combination of these
problems.

It causes symptoms which may be invisible, and also about which the
sufferer may feel unable to speak, as they relate to highly personal
bodily functions.

Loss of bladder and bowel control can be extremely distressing and
have a highly negative impact on social life, work and relationships.
There may be frequent urinary infections.

Loss of sexual function can be devastating to the sufferer and his/her
partner and may lead to relationship difficulties and depression.

Severe nerve-type (neurogenic) pain may be resistant to treatment and
require strong painkillers whose side-effects may cause further
problems. If the pain is chronic, it may become "centralized" and
affect other parts of the body and involve strange pains such as
electric shock type pain or pain from non-painful stimulus such as
light touch. This can lead to the sufferer being viewed as neurotic or
worse if it is not recognized. It is also very difficult to treat and
alarming for the sufferer who either begins to question his/her sanity
or fears the pain indicates some terrible underlying undiagnosed
disease such as cancer.

Neurogenic pain tends to be worse at night, which can interfere with
sleep and thus exacerbate the general debility it causes. Another
feature of this type of pain, and a diagnostic one at that, is pain
felt in numb areas, which appears to be a contradiction in terms. This
tends to be of a burning nature and may be both constant and
unbearable.

Sensory loss may range from pins and needles to complete numbness, and
may affect the bladder, bowel and genitalia (and therefore exacerbate
the problems with these organs).

Weakness is usually in the legs and may make walking difficult. There
may be "foot drop" where the foot drags and causes trips and falls. In
some cases it may be necessary to use walking aids or a wheelchair.

Bearing in mind these problems, it is unsurprising that sufferers may
become depressed; they endure many losses: loss of health, loss of job
and social standing, loss of relationships, loss of sexuality, loss of
self-esteem. It is entirely appropriate that the sufferer and his/her
loved ones may grieve over these losses and they may need considerable
support to prevent the most serious loss of all: hope.

TREATING CES:

Acute CES requires urgent surgical treatment if there is a compressive injury.

There may be residual problems after the surgery and these may take
some months to resolve. Extensive rehabilitation using physiotherapy
and methods such as bladder re-training may be required.

Chronic CES is much harder to treat.

Pain: usually requires strong painkillers such as narcotics
(morphine/related drugs): note that the risk of addiction is very
small (around 0.1%) although the body will become accustomed to the
drugs and withdrawal symptoms may be experienced on stopping. Adjuvant
medication such as low dose an antidepressants (e.g. amitriptyline);.
anticonvulsants ,.(e.g. Tegretol; (carbamazepine)
neurontin(Gabapentin) are often helpful. Side-effects should tend to
subside after the initial couple of weeks, constipation being the most
persistent side-effect of opiates and weight gain being common with
the adjuvant medication. The sedative effects of some medication may
be beneficial if given at night as they may aid restful sleep.
However, antidepressants may adversely affect bladder and sexual
function and contribute to the problems experienced. It may be a
delicate balancing act to achieve good pain relief with the minimum of
adverse effects.

Bladder Control: depending on the exact nature of the problem, a
neurogenic bladder will need to be treated with drugs such as
Oxybutynin if it is hyper-reflexive, or intermittent
self-catheterization if the bladder is unable to empty. The latter may
give rise to a residual volume of urine in the bladder after voiding
and this causes susceptibility to urinary infections that may require
antibiotic treatment. An overactive bladder muscle(detrusor) may cause
high bladder pressures and a reflux of urine up towards the kidneys,
so regular checks may be needed to exclude any kidney damage. Use of
measures such as cranberry juice and maintaining good fluid intake may
reduce the risk of infection. Often pads may need to be worn in the
underwear to protect against leakage of urine. This of course, may be
distressing and embarrassing for the sufferer.

Bowel control: not only loss of control of feces may be a problem, but
also of flatus and the inappropriate, uncontrollable passage of gas at
inconvenient occasions may be a source of considerable embarrassment
to the sufferer. Fecal incontinence of loose stools may in fact be
helped, coincidentally, by use of painkillers such as codeine or
morphine as they tend to be constipating. However, extreme
constipation causing impaction of feces can lead to overflow of
diarrhea around the impacted fecal mass. Most commonly in CES, it is
difficult to empty the bowel, sensation in the rectum being diminished
and propulsive action reduced. It is often necessary to assist the
bowel to empty and there are a variety of methods available. Eating a
high fiber diet and maintaining good fluid intake are useful general
measures and using a stimulant laxative on a regular basis can
facilitate matters.

Weakness: physiotherapy may be helpful provided that there is no
inflammatory component, as in arachnoiditis, where exercise may
exacerbate the condition and cause a "flare-up."

Sexual dysfunction: very difficult for people to discuss. It may be
best to seek advice from specialists in this medical field; if no
physical treatment is feasible for improvement of function, then the
sufferer (and his/her sexual partner if appropriate) should be offered
counseling, which may help lessen the impact this disability could
have on the sufferer both as an individual and as part of a couple.

Sensory loss: there is little conventional treatment but in conditions
such as MS, use of vitamin B complex is considered to have possible
beneficial effects.

Sore feet: loss of muscle tone and control over movement of the foot
may lead to pain in the foot. If foot drop is a significant problem, a
brace to hold it in position may be helpful. However, it is important
to try to maintain as much muscle tone as possible and range of
movement (ROM) exercises may assist in this.

Poor circulation: this is quite a common problem: the feet may be cold
and may turn white, then red when rewarmed(Raynaud?s syndrome) as well
as chilblains: there are some medications that can be taken, but it is
probably best to use general measures such as avoiding getting cold
feet (thick socks etc.) and also foot massage with warm oil may help
improve circulation. Avoid very hot baths after the feet have been
cold as this is more likely to cause chilblains.

Depression: this being an understandable and normal reaction to a
debilitating illness, antidepressant medication should be reserved for
severe depression, the preferred management being counselling and
support. The sense of isolation may best be addressed by contact with
support groups such as the online Cauda Equina Syndrome Support
Group,(CESSG).

These groups perform a vital role in allowing free and frank
discussion: ?mentioning the unmentionable?. Shared experiences can
help sufferers to come to terms with the disabilities CES causes them.

*****

I've provided 2 links for the online Cauda Equina Syndrome Support
Group, (CESSG) at the end of my answer.

=================================================

http://www.caudaequina.org/issues/whatisces.htm

WILL OUR NERVES REGENERATE?

Nerve regeneration will depend on how long those nerves were crushed
and how much damage has been done. The only way to know is to wait.
Doctors tell us that if the nerves are going to regenerate it can take
as long as two years.

When a nerve is crushed there are three possible outcomes. The nerve
may be "asleep" when there is enough pressure to cause it to
completely shut down. It will come back if the pressure is removed
soon enough.

The second possibility is when there is a little more pressure and the
nerve branch, called an axon, is destroyed, but the insulation, called
the myelin is still intact. The nerve can re-grow it?s axon if the
myelin sheath is still there to give it a guide back to where it is
supposed to go. The rate of growth under the best conditions is 1mm
per day. That is about one inch per month.

The third condition occurs when the axon is crushed and the myelin
sheath is disrupted. The nerve will try to grow it?s axon, but doesn?t
have a guide to find it?s way back to where it belongs. In this case
nerve regeneration is not possible, at least not at this time.

=================================================

MedicineNet.com
http://www.medterms.com/script/main/art.asp?articlekey=7240

Cauda equina syndrome: Impairment of the nerves in the cauda equina,
the bundle of spinal nerve roots that arise from the lower end of the
spinal cord. The syndrome is characterized by dull pain in the lower
back and upper buttocks and lack of feeling (analgesia) in the
buttocks, genitalia and thigh, together with disturbances of bowel and
bladder function.

Cauda equina: A bundle of spinal nerve roots that arise from the
bottom end of the spinal cord. The cauda equina comprises the roots of
all the spinal nerve roots below the level of the first lumbar (L1)
vertebra, namely the sacral and coccygeal nerves. So named because it
resembles the tail (Latin, cauda) of a horse (Latin, equus).

(See diagram) 
http://www.spineuniverse.com/displayarticle.php/article1302.html


(See illustration)
http://lebonheur.adam.com/pages/ency/articleImage.asp?file=19504.jpg&lang=en

=================================================

http://www.neurosurgerytoday.org/what/patient_e/cauda.asp

Cauda Equina Syndrome is a condition that may result in permanent
neurological damage such as paralysis of the bladder (urinary
retention and/or permanent incontinence - the inability to control
urination), paralysis of the bowel muscles (loss of bowel control),
sexual dysfunction, and problems causing pain and weakness of the
legs.

Left untreated, cauda equina syndrome can result in paraplegia - loss
of the ability to move or feel in the legs and lower part of the body.

=================================================

Cauda equina syndrome
http://orthopaedics.hss.edu/services/conditions/spine/cauda.asp

"Low back pain is common and usually goes away without surgery. But a
rare disorder affecting the bundle of nerve roots (cauda equina) at
the lower (lumbar) end of the spinal cord is a surgical emergency. An
extension of the brain, the nerve roots send and receive messages to
and from the pelvic organs and lower limbs. Cauda equina syndrome
(CES) occurs when the nerve roots are compressed and paralyzed,
cutting off sensation and movement. Nerve roots that control the
function of the bladder and bowel are especially vulnerable to damage.

If you don't get fast treatment to relieve the pressure, CES may cause
permanent paralysis, impaired bladder and/or bowel control, loss of
sexual sensation and other problems. Even if the problem gets
treatment right away, you may not recover complete function."

[edit]

Surgery 

"If you have CES, you may need urgent surgery to remove the material
that is pressing on the nerves. The surgery may prevent pressure on
the nerves from reaching the point at which damage is irreversible.

Living with CES 

Surgery won't help if you already have permanent nerve damage."

=================================================

What is the Cauda Equina?
http://www.thephysiotherapysite.co.uk/back/cauda_equina_syndrome.html

Cauda equina syndrome also known as Pelvic Visceral Dysfunction, is a
rare but important back pain syndrome.

"In adults the spinal cord ends in a structure called the conus
medullaris, a short cone-shaped area about 2.5cm long. This tapers to
the filum terminale where it ends. The end of the spinal cord is
usually at the level of the first lumbar vertebra, much higher than
people expect.

The lowest four sacral nerves emerge from the conus medullaris but the
five lumbar ones emerge from the enlargement of the spinal cord above
this and run downwards. These two major groups of nerves are then
called the cauda equina ("horse's tail"). This includes all the spinal
nerve roots from the first lumbar downwards.


What is the function of these nerves?

The nerves in the cauda equina are the motor nerves (controlling
movement) and sensory nerves (transmitting feelings) but also nerves
which control the pelvic organs.

These systems, the sympathetic and parasympathetic nerve systems, have
opposite effects but are both vital for the normal control of bowel,
bladder and sexual function. Feedback transmitted along these nerves
from the abdominal and genital organs is essential for these
functions.


How is Cauda Equina Syndrome defined?

"... it is defined as a complex of symptoms consisting of low back
pain, unilateral (one leg) or bilateral (both legs) sciatica, muscle
weakness of the legs, sensory disturbance (inability to feel normal
sensations), loss of visceral function (eg bladder and bowel) and
saddle anaesthesia (numbness/reduced feeling around the anus and
genitals). It is caused by a lesion of the cauda equina.


What can cause Cauda Equina Syndrome?

CES can be caused by fracture, tumours, infection, spinal stenosis and
disc herniation. The commonest cause is trauma, eg accidents.


What is the treatment for CES?

If there is a large disc protrusion treatment is emergency
decompression of the affected nerves without delay.

A discectomy operation is performed by a spinal surgeon or
neurosurgeon to remove the protruding fragment of the disc which is
compressing the nerves. Patients are operated on as soon as possible,
and in Kostuik's study they were operated on an average of 1.1 days
after onset of symptoms of CES.


What is the outcome of CES?  *(after a descectomy operation)*

Much of the information about recovery comes from the work of Kostuik
et al. In one study he reviewed the recovery from the point of bladder
function, sexual function and motor/sensory recovery.


Bladder Function
23 out of 30 people operated on had normal voiding of urine within 3
to 14 days of operation.

The seven remaining made a partial recovery of bladder function. Some
patients felt they had satisfactory bladder function even though
measurements made of bladder function showed that it had not returned
to normal.

In a study by Gleave and MacFarlane some patients took two years after
surgery to recover bladder function.


Sexual Function
8 people still had some sexual dysfunction at the last follow-up 24
months after operation.


Motor and Sensory Recovery
27 out of the 30 had full recovery of muscle function, with 3 people
having continuing weakness or abnormalities of feeling. Recovery times
varied from two days to six months, and most recovered in six months.


All patients who had residual problems after surgery had marked
sequestration of the disc material at surgery - the disc material had
protruded far enough to lose contact with the main body of the disc
and exist as an independent fragment.


Gleave and MacFarlane state that the die is cast when the disc
prolapses initially. There seems to be no evidence to support the idea
that emergency surgery influences the outcome. However, if surgery is
not performed in the presence of urinary retention there is a risk of
kidney failure and death.

=================================================

http://www.cinn.org/isc/herniation-lumbar.html

Symptoms 

The most common symptom of a lumbar disc herniation is pain. The pain
is usually described as being located in the buttock with radiation
down the back of the thigh and sometimes to the outside of the calf.
The specific location may vary and depends on which disc is affected
(and thus which nerve root is affected). The pain (and other symptoms
and signs) come from pressure on the nerve root. The pain frequently
starts as simple back pain and progresses to pain in the leg. When the
pain moves to the leg, it is not unusual for the back pain to become
less severe. Straining such as bowel movement, coughing or sneezing
are all things that tend to cause the leg pain to worsen. Very large
disc herniations may cause something known as the "cauda equina
syndrome". This is a rare syndrome caused by a very large disc
herniation putting pressure on many nerve roots. Signs and symptoms
include urinary problems (either retention or incontinence), loss of
leg or foot strength, "saddle" anesthesia (loss of sensation in the
area of the body that would be in contact with a saddle), decreased
rectal sphincter tone and variable amounts of pain (ranging from
minimal to severe). This is a surgical emergency.

Treatment

The treatment of lumbar disc herniations can be divided into two
categories, conservative (or non-surgical) and surgical. One exception
would be in the cases of cauda equina syndrome, sudden loss of foot
strength or urinary problems. In these cases, surgery would be
considered the conservative approach!

=================================================

The Department of Neurology at Massachusetts General Hospital has a
Web Forum where patients have posted questions about Cauda equina
syndrome.
 
http://neuro-www.mgh.harvard.edu/forum/SpinalCordInjuryF/2.19.9910.22AMCaudaequina.html

"I have just been told that I have Cauda Equine Syndrome. I have been
trying since my last surgery on my back in Sept. of 1997 to find out
what is wrong with me. I have had no bowel function except with the
use of a enema every other day, and my bladder only works on
contraction of my abdomnial muscles. The last surgery was on L4-L5,
L5-S1. Right now L4-L5 is ruptured again and L5-S1 is bulging very
diffusely. There is a large amount of enhancing tissue present
posteriorly and slightly lateral to the thecal sac. There are
degenerative disc changes at L3-4, L4-5 and L5-S1 with diffuse disc
bulging, loss of disc height and osteopytic ridging. Increased signal
within the posterior annuli at 3-4 and 5-1 may represent small annular
tears. The is a more focal left paracentral bulge at 3-4 flattening
the anterior thecal sac. The disc at L4-5 is ruptured and extending
into the proximal right neural foramen. From everything that I have
been told I need surgery again for the ruptured disc and scar tissue.
However, Since another surgery would only eliminate the pain in my
right leg and probably make my bowel and bladder problems worse. I'm
very very hesitate to let anyone operate on me again. The pain is very
bad but I try to ignore it. Does anyone have any experience with this?
Do you suppose since the Cauda Equina has been there for so long that
there is really nothing they can do at this point? I have been told
that Cauda Equina is a medical emergency. Is it?


(Click on 9 links for responses that have been posted regarding this article)

=================================================

A forum for Spinal Cord Injury (SCI) Care Cure Community
http://carecure.atinfopop.com/4/OpenTopic?a=tpc&f=6574035662&m=950100121

=================================================

Spinal Cord disorders message board
http://www.healthboards.com/spinal-cord-disorders/329.html

Re: cauda equina syndrome

I had surgery to remove and disc, put in screws and bolts. The clamp
pressed on the nerve and bone causing paralasis from the waist down.
Removed the screws and bolts two days later with no change in
paralasis. The dr. says 6 to 12 months for the feeling to come back.
With PT, I am walking well, but no feeling back. There is little
bladder and bowl control and feels as though everything is droped
down, which it is. I am very fortunate to have gotten back what I
have, but would be interested in knowing if there are similar cases.


(See 16 follow Up Links)

=================================================

Overview of Spinal Cord Injury Anatomy & Physiology
http://www.spinalcord.uab.edu/show.asp?durki=32105&site=1021&return=21475

Recovery

Recovery from spinal cord injury is, therefore, fairly predictable.
Persons with a complete injury by neurologic examination generally are
not expected to make any significant recovery except some improvement
in motor strength in the zone of injury. Recovery for persons with an
incomplete injury is less predictable and most recovery occurs within
the first six months; however, some additional neurologic recovery may
take place up to 18 months after injury. In a patient with a cauda
equina injury, some recovery is possible through regeneration for up
to three years following spinal cord injury since it is a peripheral
nerve type of injury.

=================================================

Cauda Equina Syndrome Resource Center  (Support Forum)
http://pub38.bravenet.com/forum/3209148401

I have recently started a support group for Cauda Equina Syndrome.
This is said to be a rare condition.  We have 24 members in just 2
short weeks.

CESSG Questions & Answers
Do you have Questions about what CES is? Have you or a friend or loved
one been diagnosed with CES and don't know what means? Here's a place
to find answers and support!

=================================================

http://www.caudaequina.org/join.html

CESSG is an international web-based support group for people who have
complications of Cauda Equina Syndrome. Currently, we have a growing
family of over 120 members. Our  group is privately run through
Smartgroups.com. We share our stories, our problems, our  heartaches,
and our triumphs. The stories and issues provided on this web site are
just a  few from many of our members.

If you think that you may have CES, it is important that you contact
your doctor  immediately or go straight to your nearest hospital. You
may not have CES, but it is always  best to be checked out by a
qualified medical practitioner. You MUST have a MRI or a  CT/Myelogram
in order to diagnose CES. We know that when CES is diagnosed and 
treated early there is a much better chance for a complete and full
recovery.

If you would like to learn more about joining Cauda Equina Syndrome
Support Group  please write to our founder and President - Vickie
Wolfe at vjwolfe@comcast.net or our Vice President - Sandi Kleps at
kleps@alltel.net  to request to join.

=================================================

keyword search:

cauda equina syndrome
cauda equina syndrome long term effects
cauda equina syndrome complications
cauda equina syndrome damage
cauda equina syndrome nerve regeneration
lumbar disc herniation
Pelvic Visceral Dysfunction


Best regards,
tlspiegel

Request for Answer Clarification by jan58-ga on 29 Aug 2004 17:07 PDT
The information is all basic. Are there peer reviewed medical articles
re the long term effects of cauda equina; the use of spinal dorsal or
other spinal stimulators to relieve pain; long-term studies of
patients with this illness;
discussions re cauda equina in recognized texts in neurology,
neuro-surgery, and physiatry ?

Clarification of Answer by tlspiegel-ga on 29 Aug 2004 18:15 PDT
Hi jan58,

Thank you for your clarification.  I'm working on finding more in
depth information for you.  I'll post my findings ASAP.

Best regards,
tlspiegel

Clarification of Answer by tlspiegel-ga on 29 Aug 2004 20:48 PDT
Hi jan58,

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
http://archneur.ama-assn.org/cgi/content/abstract/40/9/570

Neurourologic findings in conus medullaris and cauda equina injury

=================================================

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1.chapter.46140

"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."

[edited]

"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. 
http://www.dcmsonline.org/jax-medicine/1999journals/april99/endoscopy.htm


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
or inflammation.

(reference: Burman MS. Myeloscopy or the Direct Visualization of the
Spinal Canal and its Contents, Journal of Bone and Joint Surgery,
13:695-696, 1931)

*****

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
equina.

(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. 
Chattanooga, Tennessee 
http://www.aafp.org/afp/990201ap/575.html

"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."

[edited]

"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
function."

[edited]

'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."

[edited]

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
http://medpics.findlaw.com/generateexhibit.php?ID=2984&ExhibitKeywordsRaw=&TL=64&A=42409

*I'm not able to pay for the articles, however if you are interested -
here is the link for Pricing And Ordering Information:
http://medpics.findlaw.com/pricing.php?A=42409&I=4


1.  Microsurgical DREZotomy for pain due to spinal cord and/or cauda
equina injuries: long-term results in a series of 44 patients. - Pain.
2001

2.  Lumbar pannus presenting as cauda equina syndrome in a patient
with longstanding rheumatoid arthritis. - Journal of Rheumatology.
2001

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
http://eyewitnessanimations.medicalillustration.com/generateexhibit.php?ID=2961&A=

1.  Acute cauda equina syndrome after total knee arthroplasty as a
result of epidural anesthesia and spinal stenosis. - Journal of
Arthroplasty. 2000

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
http://www.sci-illinois.org/factsheets/painaftersci.htm

Neuropathic Pain 

"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."

[edited]

Pain Management

"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
rhizotomy.

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
http://www.coccyx.org/treatmen/spinstim.htm

=================================================

Spinal Cord Stimulator
http://www.neurocare.org/neuro.php?pageid=39&Name=Spinal%20Cord%20Stimulators

=================================================

Spinal cord stimulators and pain pumps - implantable systems
http://www.spine-health.com/topics/conserv/neuropaintr/neuropaintr04.html


Additional treatments
http://www.spine-health.com/topics/conserv/neuropaintr/neuropaintr05.html

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
well.
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  
http://www.asco.org/ac/1,1003,_12-002393-00_18-00,00.asp?state=AR&CAC_ArticleId=31654

The following Local Medical Review Policy (LMRP) was developed by this
state's Medicare Carrier and DOES NOT represent ASCO policy

LMRP DESCRIPTION

"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
be removed.

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."

[edited]

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY

A. INDICATIONS:

9. To treat intractable pain caused by cauda equina injury; and 

=================================================

DORSAL COLUMN STIMULATION
http://neurologicalinstitute.com/spine.html

Involves the implantation of an electronic stimulator near the spine
that interrupts the pain signal to the brain.
 
=================================================

TENS - Transcutaneous Electrical Nerve Stimulation
http://www.masters.com.au/what_TENS.htm

==================================================

ClinicalTrials.gov - Spine Patient Outcomes Research Trial (SPORT): Spinal Stenosis

This study is currently recruiting patients.

http://www.clinicaltrials.gov/ct/gui/show/NCT00000411

Inclusion Criteria:

Duration of Symptoms: 12 or more weeks. 
Treatments tried: Nonsteroidal anti-inflammatory medical therapy and
physical therapy.
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). 

http://sport.dartmouth.edu/nsn/

=================================================

Clinical Trial
http://www.controlled-trials.com/isrctn/trial/%7C/0/45641649.html


==================================================

Nerve Root Disorders
http://www.merck.com/mrkshared/mmanual/section14/chapter183/183c.jsp

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
stenosis).

[edited]

"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

http://www.arachnoiditis.com/newsletter/SPRING_03.pdf

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,
FL32459-4627E-mail: taldrete@arachnoiditis.com

=================================================

Peer reviewed article Boos N. Akute Myelopathie und Cauda-equina-Syndrom.
Schweiz Med Wochenschr 2000;130:844-50.
http://www.smw.ch/archive/2000/130-22-338-00.html

Acute myelopathy and cauda equina syndrome 

(See right side of article for English translation.)

================================================

A Case Study of Cauda Equina Syndrome 
http://xnet.kp.org/permanentejournal/fall03/study.html

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
http://www.vh.org/adult/provider/familymedicine/FPHandbook/Chapter16/01-16.html

Treatment. 
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
effective.
 
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
of time.


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
Neurological Surgeons
  
June 2004, Volume 16, Issue 6
 
1. Spinal epidural hematoma causing acute cauda equina syndrome.
Khaled M. Kebaish and John N. Awad
http://www.aans.org/education/journal/neurosurgical/june04/16-6-1.pdf

2. Infectious origins of cauda equina syndrome. David B. Cohen
http://www.aans.org/education/journal/neurosurgical/june04/16-6-2.pdf


3. Cauda equina syndrome caused by primary and metastatic neoplasms.
Carlos A. Bagley and Ziya L. Gokaslan
http://www.aans.org/education/journal/neurosurgical/june04/16-6-3.pdf


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
http://www.aans.org/education/journal/neurosurgical/june04/16-6-4.pdf


5. Cauda equina syndrome after induction of spinal anesthesia. Serdar
Ozgen, Nigar Baykan, I. Varlik Dogan, Deniz Konya, and M. Necmettin
Pamir
http://www.aans.org/education/journal/neurosurgical/june04/16-6-5.pdf


6. Cauda equina syndrome in patients with low lumbar fractures. Issada
Thongtrangan, Hoang Le, Jon Park, and Daniel H. Kim
http://www.aans.org/education/journal/neurosurgical/june04/16-6-6.pdf

7. Cauda equina syndrome as a postoperative complication of lumbar
spine surgery. Randy L. Jensen
http://www.aans.org/education/journal/neurosurgical/june04/16-6-7.pdf


8. Medicolegal consequences of cauda equina syndrome: an overview. John P. Kostuik
http://www.aans.org/education/journal/neurosurgical/june04/16-6-8.pdf


=================================================

Neurology
http://www.neurology.org/cgi/content/full/56/11/1607

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.
https://secure.highwire.org/cgi/secure_ppv?type=ppv&resource_id=56/11/1607&jcode=neurology&data=Cauda+equina+syndrome+from+intradiscal+electrothermal+therapy~Wetzel+et+al.~56~11~1607~12+Jun+2001&url=http%3A%2F%2Fwww.neurology.org%2Fcgi%2Fcontent%2Ffull%2F56%2F11%2F1607

*****

Neurology 
http://www.neurology.org/cgi/content/full/52/4/890
Compression of spinal cord and cauda equina in Charcot-Marie-Tooth disease type...
BŁtefisch et al. Neurology.1999; 52: 890 

https://secure.highwire.org/cgi/secure_ppv?type=ppv&resource_id=52/4/890&jcode=neurology&data=Compression+of+spinal+cord+and+cauda+equina+in+Charcot-Marie-Tooth+disease+type...~B%26uuml%3Btefisch+et+al.~52~4~890~01+Mar+1999&url=http%3A%2F%2Fwww.neurology.org%2Fcgi%2Fcontent%2Ffull%2F52%2F4%2F890

=================================================

Cauda Equina and Conus Medullaris Syndromes
http://www.emedicine.com/neuro/topic667.htm

=================================================

Epidural compression of the cauda equina caused by vertebral
osteoblastic metastasis of prostatic carcinoma: resolution by hormonal
therapy
http://jnnp.bmjjournals.com/cgi/content/full/68/4/514

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.

(see report)

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

http://www.jpgmonline.com/article.asp?issn=0022-3859;year=1998;volume=44;issue=1;spage=14;epage=5;aulast=Singh

Traumatic transverse fracture of sacrum with cauda equina injury--a
case report and review of literature

=================================================

Spinal Cord Injury Association - What Reduces Pain
http://www.sci-illinois.org/factsheets/painaftersci.htm

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.

Conclusion

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.
http://www.spinalcord.uab.edu/show.asp?durki=21605

(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
this area.


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
800-257-5126  
Email: custserv@films.com 

This video tells the story of one man who choses to have a spinal cord
stimulator implanted to help control pain. A Discovery Channel
Production.
Time: 24 minutes 
Cost: $129 / Rental: $75


Neuralyn Therapy


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)
Email: nacpac@chronicpaincanada.org
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.


Pain Online
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 
913-864-4095 
Date: 1993-1996

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.

=================================================

Best regards,
tlspiegel
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