70 y/o M with history of DISH, T10-L3 PSIF and T12-L1 laminectomies after a prior fall with hyperextension injury. Now presenting with progressive bowel/bladder incontinence and difficulty ambulating.
Severe central stenosis with compression of the cauda equina at multiple levels.
These fluid sensitive sequences make compression of the nerves easiest to appreciate. The bright CSF signal is not seen surrounding the nerve roots in areas where the thecal sac is severely compressed.
Cauda equina syndrome is caused by severe compression of the descending lumbar and sacral nerve roots. Patients can present with acute or chronic symptoms, although traditionally we think of the acute presentation when discussing "Cauda equina syndrome". If that term is to be accurately applied to a patient, they must have both of these conditions met:
Other associated signs and symptoms include lower back pain and lower extremity symptoms including radicular pain, weakness, or sensory changes.
Cauda equina syndrome is a clinical diagnosis. The role of the Radiologist is to identify structural abnormalities that could potentially cause these reported symptoms. As such, you shouldn't "diagnose" cauda equina syndrome in your report. Many people have severe central stenosis and compression of these nerves without having the constellation of findings seen in cauda equina syndrome. It is likely best to simply describe "compression of the cauda equina at such and such levels". If the appropriate history is explicitly provided to you by the referring provider, you could say something like "... severe compression of the cauda equina is concerning for cauda equina syndrome given the reported symptomatology".
Our patient presented with progressive bowel/bladder dysfunction with trouble ambulating. The neurosurgery notes describe a sub-acute to chronic cauda equina syndrome and he underwent decompressive laminectomies at L3-L5 with subsequent symptomatic resolution.
In this case, compression of the cauda equina was secondary to a combination of facet hypertrophy, ligamentum flavum hypertrophy, and multi-level broad based disc bulges.
There are many possible etiologies of cauda equina syndrome. It can be secondary to anything that is causing compression of the nerve roots (e.g. degenerative changes, post-traumatic, infection, neoplasm, vascular abnormality, etc.).
This Radiographics Core/call-prep article is an excellent HMC call primer describing the normal spinal anatomy and findings in non-traumatic cord compression. Please see our other pacsbin case for a discussion of traumatic spine injuries.
Neurosurgical consult for possible surgical decompression.
Nontraumatic Spinal Cord Compression: MRI Primer for Emergency Department Radiologists. Retrieved November 17, 2020, from https://pubs.rsna.org/doi/10. 1148/rg .2019190024.
Imaging in cauda equina syndrome-a pictorial review. McNamee J, Flynn P, O'Leary S et-al. Ulster Med J.82 (2): 100-8.
Cauda equina syndrome: Radiology Reference Article. Retrieved November 17, 2020, from https://radiopaedia.org/articles/ cauda-equina-syndrome?lang=us