Lower Thoracic, Conus, and Cauda Equina Injuries: Diagnosis & Treatment

[RJB]

Dr Wise Young,

On 10 Dec 2011, I suffered a spinal injury after falling about 10-15 feet. I was told that the injury resulted from excessive flexing as I was doubled over on impact with the ground. The initial write up from the Neurosurgeon stated that I had a closed fracture of lumbar vertebra with spinal cord injury. There was a fracture dislocation at T12-L1 with fracture of the L1 body also. There was a spinal cord compression at the level of deformity with abnormal signal in the cord extending superiorly, and there were signs of conus medullaris syndrome. Majority of muscle groups below the level of injury are greater than 3/5. Sensation decrease over LE with no rectal sparing. I had incomplete sensory loss rectum and decrease rectal tone. They conducted a posterior decompression at T12-L1with reduction of deformity with T10-L3 instrumented fusion. There was weakness and evidence to suggest I would have bowel/bladder and sexual dysfunction.

Another report stated the following: A CT scan of the spine revealed an anterolateral fracture of the L1 vertebral body with the T12 facet perched on top of L1 bilaterally with TP fractures noted. MRI of the spine was then performed which demonstrated abnormal signal in the conus to the lower spinal cord at T11. Patient subsequently underwent T10-L3 posterior segmental instrumented fusion with decompression and T12-L1 partial inferior and superior laminectomy with bilateral facetectomies.

Initially in the hospital I was unable to lift my right leg, while straight or bent, against gravity, but I could lift my left leg. I had decreased sensation down the posterior sides of my legs and minimal feeling in my pelvic area and feet. At first I couldn’t walk but after a couple days I could get myself up with a walker. Eventually after a week I could walk around with the walker and after 2 weeks I could walk with just a cane. Around that same time I was able to lift my right leg against gravity. Within two months I could walk without a cane or any other assistance and have been able to do so ever since. My gate has greatly improved, however, I still have a limp since I walk on my heels, but I can walk over a mile without assistance. My inability to fully use my calves prevents me from moving normally, and I cannot stand on my toes except when in water about waist deep.

I still have numbness on the posterior sides of my legs but I can feel some sensations. I have not had the pin/touch sensation test done recently but can get that assessed at my next doctor visit if that will help. The numbest area of my body is still the pelvic area. I can feel fullness in my bladder and some irritation to my urethra during cathing but I do not have much sensation. I should also have urodynamic testing done in the next couple of weeks. Also, initially I could not get an erection, but now I can and have some ability to ejaculate despite almost no sensation in my penis but I have no control of when it occurs. As for bowel control, I am still on a bowel program and I have to manually remove stool once a day since the anus has enough tone to hold stool in through most of the day. In addition, within the last couple months I have developed the ability to expel the majority of waste by pushing if I manually loosen the anus. I have been seeing a pelvic floor specialist and doing biofeedback tests and when clinching it shows a small increase.

I am currently coming up on 6 months from my accident and hopeful to keep improving. I have been having issues with bad sciatica in my lower back and right hip that shoots down my right leg, and will have nerve conduction testing done next week. I have been reading a lot of the posts on here and have become curious if my symptoms are more closely related to a conus injury or a lower thoracic injury and what that will mean for continued recovery? I know due to the location of my injury and the report, I would have guessed lower thoracic, however, it seems like I have more of the indications of what I have seen described for a conus injury. I would also guess since my injury is at L1 it is too high for cauda equine.

[MFlounlacker]

I really don't want to sound like a smart ass because I am curious. Maybe I have missed something. I was injured 12/11 and was fused at the T-11-L1. I suffered a complete dislocation and resultant SCI.

To my knowledge I have never had any tests to determine my nuerological level of injury. My rehab doctors acted as if they were tryint to figure out the nature and extent of my injuries but then I left Kernan and that was that.

I have had amozing amounts of return so far and am very thankful. I now walk with fore arm crutches and rarely use my wheelchair anymore.

I guess my question is what difference would it make to know whether my injury is lower thoracic, conus, or equina? Would they want to treat me differently? Am I missing something?

Again I am not trying to be a smart ass. Ever since I left Kernan and been doing outpatient therapy I have been the one doing all the research to aid in my recovery. I would like to know if I need to get some testing done that may help guide my treatment.

[SCI-Nurse]

Did you never have an ASIA exam? That would be the standard of care in a SCI rehab program (at both admission and discharge). It does not really alter your treatment to know accurately, but having a good ASIA exam allows later comparisons to be made that can document the return that you are getting.

We send all of our SCI rehab patients home with a written copy of their discharge ASIA exam (as part of their discharge personal portfolio) so that they can use it for comparison in the future regardless of where they get further care.

(KLD)

[MFlounlacker]

I was given the ASIA exam but it seems that many of the symptoms over lap when determining the exact nature of my injury. Pretty sure that I was released as ASIA C and a lower body score of like 5/50. But none of that followed me to outpatient. I was evaluated there as well but have not seen those scores.

I don't need another ASIA exam to know that I am far above the scores at Kernan now and really don't care what classification I am as it evidently makes no difference. I am what I am.

I was just wondering if I may be missing the boat on this and would not be surprised in the least that the doctors and Pt's I saw at outpatient didn't really know how to treat SCI.

I have since ceased therapy as it has seemed to digress into a waste of time and money. I do my own therapy at home and exercise regularly. I do my own research and adjust my work outs accordingly.

Thank you for your response KLD. You guys are great.

[TM from PA]

Hello , I was told i have TM leasons at t11L1 and nuro. said at the tip of the conus at S1 i have no ankle movement at all and no feeling at top of toes. does that mean i have a conus injury even though no blunt injury.