Cauda equina injury: Diagnosis and Treatment

[Wise Young]

Original Topic

Originally posted by Dennis Chan:

Dr. Young,

I just went to see my surgeon for one year post operation appointment. He told me that my injury level is at vertebral L2 and that it is cauda equina injury. However, he doesn't know for sure if there is conus injury involved. But it definitely is not SCI.
My current situations are these:
1. I regained all my motor function to various degrees on my right leg and right foot.
2. Other than a small amount of calve muscle working on my left leg, I have no left leg motor functions. For example, I don't have any left quadricep function. I can move a little of my small toes but not the big toe on my left leg. I regained a small amount of my left butt muscle function.
3. I regained a large amount of sensation on the back of both of my legs. More so on the right leg than the left leg. However, I have no sensation in the front of both of my legs.
I regained most of the sensation on my right foot and some small amount of sensation on my left foot.
4. I regained most of the sensation on both sides of my butt.
5. I regained my bowel movement and urine functions.
6. Very rarely do I get erection and even if I do get it, it lasts about 15 seconds.
7. I have no muscle spasm other than occasional cramp on my right toes especially the big toe.
8. I get neuropathic pain on both of my legs and feet that can last from half an hour to 24 hours. The pain is similar to static electric shock that lasts about a few seconds but then repeat every 15 seconds or so.

Questions:
1. How do I find out if I have conus injury as well? Would an MRI scan tell me that?
2. How are L2 vertebral injury different than L2 spinal cord injury?
3. Are there any treatment for cauda equina injury? For example, AP-4 drugs and/or OEG surgery in Beijing.
4. Do you know any expert in cauda equina injury that you would recommend to me?
5. Are there any drug for neuropathic pain such as neuronton?
6. Are there any drug for my right toes cramps?
7. Do you recommend any electrical stimulation of my atrophy muscles on left leg so I can exercise them?

Thank you so much for your answers.

Dennis Chan

Dennis,

Based on your description, you do seem to have cauda equina injury. It would be very helpful if you fill out the ASIA classification form. Your sensory loss on the front of your legs indicate that you have damaged your L1-L5 roots, particularly on your left. The fact that you have recovered sensation in your butt and the back of your legs (S1-S2) indicate that you have spared most or perhaps all your sacral roots. You should have sensation of your penis (S2). Your recovery of bowel function (and presumably anal sphincter S4/5) and bladder (S3) function confirms this. The fact that you cannot move your big toes (L5). Do you have ankle flexion, particularly on your right?

You probably do not have conus injury, which would have damaged the lower sacral segments. Since your S1-S5 seems to be intact, this argues strongly against a conus injury. Concerning therapies, the first and most proximate concern is whether you have tethering of your spinal roots. If so, untethering and removing scar tissues that may be adhering the roots to each other and the dura may help restore some function. It is possible that some of the regenerative therapies that are now being applied to the spinal cord may stimulate regeneration of axons in the roots. Several groups have reported that OEG cell transplants may facilitate regrowth of sensory axons back into the spinal cord. There is no good answer to your question concerning neuropathic pain, particularly the intermittent type that you describe. You can try neurontin to see if it helps. Finally, some nerve transfer may help if you have one or two muscles that you would like to get back but there is a limit to the number of transfers/bridges that can be done.

The one doctor that I know who has a strong interest in and specializes in surgery for cauda equina injuries is Jim Guest at the Miami Project.

Wise.

[diane2]

Wise, Could you comment on this client:
Injury post 14 months
Vertebral level T12 -L1 burst steroids <4hrs. one level segmental depression <18 hrs.
Both PT and last physiatrist suspect more caudal equina involvement

ASIA last year

Motor Sensory
Normal to L1 Touch pin
L2 4 3
L3 4 3 Normal to L3
L4 0 0 1/1 2/1
L5 0 0 1/1 2/1
S1 0 0 0/1 1/0
S2 2/2 2/2
S3 1/1 0/0
S4-5 0 0 1/1 0/0

Last test above last year and some improvement has occurred both sensory and motor.
Functional: walk about 100' with crutches, stand x 20 minutes; weak but not absent gluts and hamstrings. PT thinks she can activate some foot movement via NDT.

EMG: Positive BCR refexive contraction of external sph. Intact peripheral nerves documented by normal right sural and superficial peroneal sensory studies

Tx plan: fitness, investigating Lite Gait & FES (no good reseach to guide here) Easystand glider?
Can you add anything? Do you think it is mostly cauda equina? If so, how does that impact tx plan and outcome. Thank you.

[diane2]

sorry, chart didn't turn out as thought. Should be space between groups of numbers. Motor and Sensory on same line. First motor(R/L) then light touch (R/L) then pinprick (R/L)

[Wise Young]

Diane, I don't have much time but my first impression is that this is not a cauda equina injury nor conus. The injury involves L4-S1 but partly spares the conus (S2-5). A cauda equina injury can produce these symptoms but let me look at this more carefully. Will post later. Wise.

[DennisChan]

Dr. Young,

Thanks for your reply.

1. I have sensation on my penis but virtually no erection. Any therapy that would help in restoring my sexual function?

2. I can move my right big toe. I have ankle flexion in my right foot. But I cannot move my left big toe and no ankle flexion in my left foot.

3. How do I find out if I have tethering of my spinal roots? Could a MRI scan reveal that? My surgeon did an uncompression of my spinal cord. Should that take care of the tethering?

4. If I want to restore my left quadricep muscle, could nerve transfer/bridge help?

5. What's Dr. Jim Guest's contact email?

Thanks,

Dennis

[Leo]

Hi Denns, I think this is his email address, jguest@med.miami.edu

"All you have to decide is what to do with the time that is given you."
Gandolf the Gray

[diane2]

Wise, Take your time, but better yet wait until July until after the next ASIA exam. Will give you the new numbers then (if things have changed). This is actually not a straightforward case and there has been much difference of opinion and so your thoughts are welcome. Main goal: find tx options and not just debate diagnosis. Also planning a visit to RIC. Can we communicate with you another way so it is not so "public"?

[DennisChan]

Dr. Young,

I woke up this morning and was very surprised to find that there is a lot of semen in my underwear. I don't recall I had some sort of erotic dream or wet dream last night. Does it mean that my erection and ejaculate functions are coming back? This is the first time this happens since my L-2 injury one year ago.

Thanks,

Dennis

[Wise Young]

Dennis, seems like a wet dream to me. It suggests that your brain does have some connections to your lower spinal cord. Wise.

[DennisChan]

Dr. Young,

How do I find out if I have tethering of my spinal roots? Could a MRI scan reveal that? My surgeon did an uncompression of my spinal cord. Should that take care of the tethering?

Thanks,

Dennis