Announcement

Collapse
No announcement yet.

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

Collapse
X
 
  • Filter
  • Time
  • Show
Clear All
new posts

    #16
    Wise...This is exactly the information that I was seeking when I started the thread "Is there any hope...". Ever since I started coming to CareCure I have had to glean whatever data I could from the posts about Quadraplegia and Paraplegia and attempt to apply whatever I could to my own injury. It's kind of like fitting a square peg into the round hole.

    Due to the sheer numbers of quads and upper paras, we low thoracic, lumbar, conus and cauda equina injuries don't get a lot of posts that specifically address our own set of unique deficiencies. With this one article you have given me, and probably many more CC members, more knowledge about our injuries than has probably been posted on CC ever before! THANK YOU!

    I had an L1 burst fracture from a fall where I landed on my buttocks in a sitting position. The posterior 1/3 of the L1 vertebra broke off and jammed itself into the spinal cord, compressing it and causing hemorraging in the interspinous ligament. This data I got from the orthopedic surgeon's post-op report and the x-rays. Since the x-ray films have faded so much they can't be copied, here is a picture of what my spine looked like upon admittance: (see pic below)
    <pre class="ip-ubbcode-code-pre"> </pre>

    The neurologist's reports from my last exam (1 year ago) state "burst fracture injury of L1, with biomechanical lumbar abnormalities, injury to conus medallaris of spinal cord and cauda equina problems." He also states "neurological impairment of S2/S4..." and goes on to describe my bowel, bladder and sexual disfunction. Another part of his report states "reflexic-atonic bladder/bowel difficulties w/ erectile difficulty. Rectal sphincter tone was lax and bulbo-cavernosus and cremasteric reflex are absent". In his summary he mentions "cauda equina lesion (incomplete)".

    I am going to take the ASIA worksheet and get it to you for your observations and comments. However, from what the neurologists have stated in these reports, it looks like I've got a triple whammy of SCI, Conus and CE injury. It seems like a miracle that I can still walk or is walking something completely unrelated to the neurological injuries that I have?

    Can you offer any direction as to what type of treatments it would take to restore BBS and what is being studied by whom that will address these issues?

    Thanks again, Wise.

    Kap

    accept no substitutes
    Last edited by Wise Young; 28 Sep 2006, 4:18 AM.
    accept no substitutes

    Comment


      #17
      Wise...For those of us taking the ASIA test ourselves can you give some guidance on specifically what is meant by "light touch" and "pinprick"?...ie: how much pressure to apply? is it a light touch w/ a pencil eraser, fingertip or flat hand? is the pin held perpendicular to the skin or angled? should the pinpoint depress the skin or just touch it?

      This would lead to more accurate results for us doing it at home.

      Thanks

      Kap

      accept no substitutes
      accept no substitutes

      Comment


        #18
        MikeC, let me summarize based on your description. Please correct me if I am wrong.

        Vertebral injury: T12 burst fracture

        L/R Motor
        L2 ?/? (Hip flexors)
        L3 5/5 (Knee extensors)
        L4 4/3 (Ankle dorsiflexors)
        L5 0/2 (Long toe extensors)
        S1 0/0 (Ankle plantar flexors)

        L/R Pin Touch
        L4 2/2 2/2 (front of leg above knee)
        L5 1/0 1/0 (medial top of foot)
        S1 0/0 0/0 (heels)
        S2 2/0 0/0 (kneepit)
        S3 0/0 1/0 (butt crease)
        S4 0/0 0/0 (perineal)
        S5 0/0 0/0 (anus)

        From your description, the T12 burst fracture damaged your S3 spinal cord on your left. I surmised this from the loss of pin and touch sensation from S3 to S5. The question is whether you have damage to your L5 through S2 roots. Damage to your L5 through S2 roots on your right, as well as your L5, and S1 spinal roots on your left, and sparing of your left S2 root would explain the distribution of your sensory findings. The fact that you can feel a full bladder may come from sparing of your left S2 root. Bilateral S1 root damage is consistent with flaccid paralysis of your calf muscles (plantar flexors).

        There are several inconsistencies in the distribution of neurological deficits with the above explanation.

        1. Preservation of your right big toe movement but absence of right L5 sensation. The big toe (extensor hallucis longis) is partly supplied by L4 and L5, but you also say that you have greater weakness of your right ankle dorsiflexors (L4). One possible explanation may be extension of damage to your right spinal cord up to L4, resulting in a Brown-Secquard like syndrome. Do you have any spasticity?

        2. Loss of L2 motor function with no change in sensory. When you say that you cannot lift your legs from a lying down position, are you referring to a straight leg raise? Can you do a sit-up with somebody holding your knees down? In other words, do you have hip flexors?

        3. Sensation to your penis is carried by S2 or S3 root, usually on one side (varies from individual to individual). Since you appear to have spared your left S2 root and your S2/3 spinal cord is at least partly intact (erection and ejaculation), do you have any penile or scrotal sensation at all?

        I would recommend the following diagnostic tests that Dr. Aleksandar Beric (tel: 212-598-6294, fax: 212-598-6009) who is an expert on clinical neurophysiology of people with suprasacral and sacral spinal cord injuries at NYU Medical Center.
        • lumbosacral somatosensory evoked potentials.
        • electromyography of affected roots, to determine whether there are reflexes carried by the lumbosacral roots.

        In terms of therapy, as I had pointed out below, there is the possibility (once you have identified what remains, which roots are intact and which roots have been injured) of doing bridging, possibly combination olfactory ensheathing glial cell injections and growth factor administration into the dorsal root entry zones to encourage sensory axonal regeneration into the spinal cord (by the way, there is some animal data suggesting that OEG will encourage axonal regeneration from root to spinal cord, etc.

        Wise.

        [This message was edited by Wise Young on 05-17-05 at 10:38 AM.]

        Comment


          #19
          Kap, touch is light touch using a wisp of cotton with a Q-tip. Pinprick is with a sharp pin. Wise.

          Comment


            #20
            Dr Young, my wife says that you've already figured out how to clone yourself - that's the only way you can spend as much time with us as you do! Just a small joke to say thanks for your response.

            Your summary of my results is right except that for S2 I can feel both the pin and the q-tip on the left side (behind the knee). I'm not sure what the difference is between a "1" and a "2" for sensory - I thought either you could feel it or you couldn't.

            To answer your questions:

            1. Yes, I also find it odd that my left side is so much stronger and with more feeling but it's the big toe on my right side that moves. I keep trying to move the toes on my left side but no luck even though I can feel the big toe and the one beside it real well. I do have spasms at night. I can't tell if my butt and calves tighten but my legs do - the spasms usually wake me up.

            2. Sorry I was confusing on my motor function. Yes, I would say my hip flexors are a 5. I can do sit ups (I wasn't sure what hip flexors are) and when I lay on my back I can lift my legs straight up with 5 lb weights without any problem. What I can't do is move my legs sideways (are those abductors?) with any strength. In rehab they would have me try to keep my legs spread and they would push them together without too much effort. I have a lot of strength moving my legs together - its just spreading them sideways that I am weak.

            3. I've got touch sensation in my scrotum and can feel the base of my penis (maybe the first half inch or so). When I insert a catheter I can feel the scraping in my penis (it's kind of like novacaine from the dentist in that it doesn't hurt but I can feel the pressure and movement).

            With these facts can you figure out if I've got a Conus or a Cauda Equina injury or do I need to get the tests done that you recommend? I thought I'd ask the VA to do the tests in Nov when I have my annual check-up unless you think I should have them done sooner.

            Thanks again for your help.

            Mike

            T12 Incomplete - Walking with Crutches, Injured in Oct 2003
            T12 Incomplete - Walking with Crutches, Injured in Oct 2003

            Comment


              #21
              Originally posted by Wise Young:


              I would recommend the following diagnostic tests that Dr. Aleksandar Beric (tel: 212-598-6294, fax: 212-598-6009) who is an expert on clinical neurophysiology of people with suprasacral and sacral spinal cord injuries at NYU Medical Center.
              • lumbosacral somatosensory evoked potentials.
              • electromyography of affected roots, to determine whether there are reflexes carried by the lumbosacral roots.
              dr young..i keep writing fr wise,, sorry it fits! you may not always be young , however you always will be wise!
              you may have answered what i have been thinking about for the last couple of weeks.
              where can i go in NYC to find an expert on cauda equina injuries and everything it encompasses.
              the physical therapy up here is not worth my time.

              my left leg and foot atrophy is severe , however i know there are a couple muscles that are not denerved in there, i know i have the half arterial blood flow from the knee down compared to my good leg from the bone scan. that was last year and the atrophy and muscle wasting is much more severe now.. not sure if this AFO is making the problem worse, however it help so much with my walking i cant go without it. it also reduces the ankle trauma i get from constantly reverting the ankle, NYU is easy for me to get to , ortho AAFOS doc is there.
              my bowels are a mess since i stopped the ultram, going every hour or 2 for a couple weeks now.
              do you other lower level injuries have this atrophy ? atrophy pic

              [This message was edited by metronycguy on 05-17-05 at 11:18 PM.]

              [This message was edited by metronycguy on 05-18-05 at 12:15 AM.]
              cauda equina

              Comment


                #22
                MikeC,

                First, you don't have either cauda or conus injuries. What you have is a T12 burst fracture with a L4 neurological level. The ASIA classification system defines the neurological level as the lowest "normal" neurological segment.

                Second, in terms of the actual location of spinal cord and root damage, you have damaged your S3 spinal cord. I think you also damaged your left L5 and S1 spinal root and your right L5 to S2 spinal root. Another possibility is that you have damage or extension of the damage to your L5 spinal cord on the right side. But, it is not possible to distinguish these two possibiliites without a more detailed reflex examination and/or neurophysiological test of the L5 to S2 roots.

                Based on your new information, the following are your revised ASIA information. Sensory scores of 0, 1, or 2 where 0 indicates no sensation, 1 is abnormal sensation, and 2 is "normal".

                L/R Motor
                L2 5/5 (Hip flexors)
                L3 5/5 (Knee extensors)
                L4 4/3 (Ankle dorsiflexors)
                L5 0/2 (Long toe extensors)
                S1 0/0 (Ankle plantar flexors)

                L/R Pin Touch
                L4 2/2 2/2 (front of leg above knee)
                L5 1/0 1/0 (medial top of foot)
                S1 0/0 0/0 (heels)
                S2 2/0 2/0 (kneepit)
                S3 0/0 1/0 (butt crease)
                S4 0/0 0/0 (perineal)
                S5 0/0 0/0 (anus)

                Wise.

                Comment


                  #23
                  Metro - your left calf looks just like both of mine! Sure wish one of mine still looked like your right calf.

                  Dr Young - Thanks again - you're really educating me (and hopefully others). Afraid I'm really feeling stupid, er, uneducated now. I know I had a T12 but thought that I also had a conus or cauda equina. How can you tell the difference?

                  A far simpler question - when you say 'butt crease' to test S3 do you mean the crack of my butt or where the butt meets the thigh?

                  Thanks,
                  Mike

                  T12 Incomplete - Walking with Crutches, Injured in Oct 2003
                  T12 Incomplete - Walking with Crutches, Injured in Oct 2003

                  Comment


                    #24
                    mike c , yes i know i am very fortunate to have the right leg still working ok so far..
                    my upper quad muscles are visible smaller, hamstring is much weaker and smaller too.
                    i just wonder how much longer the leg will hold up. i do walk a lot with the AFO, so its not due to non use, the muscle had died and turned to fibroid per my doc today, says nothing can be done.
                    cauda equina

                    Comment


                      #25
                      I guess that the S3 can be both the crease between the leg and the buttock, as well as the upper midline of the cleavage between the buttock.

                      A conus injury is defined as an injury to S4/5 of the spinal cord, the tip of the spinal cord. It is possible that you also have damage to S4/5 but to distinguish that you would need to see if the S4/5 gray matter is intact. That is not easy to test clinically since your sphincter is paralyzed. On the other hand, as you point out, you have some sensation there.

                      A cauda equina injury is defined as injury to the cauda equina which begins below L1. If you had a burst fracture of the L3 vertebra, it would be more likely to be a cauda equina injury.

                      Wise.

                      Comment


                        #26
                        OK Wise...time to do me now...LOL!

                        Here's my scores on the ASIA test. I'm only listing those that were impaired or absent as much was normal:

                        Level/Touch/Pin Prick
                        * * * R/L * * * R/L
                        C2* * * * * * * 1/1
                        C5* * * * * * * 1/1
                        C6* * * * * * * 2/1
                        C7* * 0/0
                        C8* * 1/1
                        T1* * * * * * * 1/1
                        T2* * * * * * * 0/0
                        T3* * * * * * * 1/1
                        T4* * * * * * * 1/1
                        T5* * 1/2
                        T8* * * * * * * 1/1
                        T11 * 1/1
                        T12 * 1/2
                        L1 * 0/1 * * * 1/1
                        L2 * 1/2
                        L4 * 0/0 * * * 2/1
                        L5 * * * * * * 2/1
                        S1 * 1/0 * * * 1/0
                        S2 * 1/1 * * * 1/1
                        S3 * 1/1 * * * 0/0
                        S4-5* 1/1 * * * 0/0

                        (Ignore the little stars above. They are just place holders as for some reason the numbers keep collapsing when posted.)

                        No = voluntary anal contraction; Yes = anal sensation.

                        Motor = all 5/5 except wrist extensor L =4 and ankle plantar flexors = 4. I fell down my front steps(1/2 flight) backwards head over heels at 1 1/2 yrs post and fractured left wrist, so it's probably from nerve damage from surgery on metacarpal.

                        I am a bit concerned about the impairment of C5-C8 also. Possibly did something to neck in fall but have never had MRI or x-ray of C-spine so don't know. X-ray of T and L spine showed no damage to fusion.

                        I am curious if this indicates cauda equina and conus injuries as well as SCI. If you couple this data with my previous post and drawing of my injury...what's your opinion?

                        Also...can you tell what my neurological level of injury and function are from this, even though my vertibral level is L1?

                        Kap

                        accept no substitutes

                        [This message was edited by Kaprikorn1 on 05-19-05 at 12:41 AM.]

                        [This message was edited by Kaprikorn1 on 05-19-05 at 12:45 AM.]
                        accept no substitutes

                        Comment


                          #27
                          Kap,

                          The data you present would be reason to hospitalize you immediately. You should not have any loss of sensation above your injury level. 0/0 for C7 would be very worrisome. Are you sure that you are totally numb to touch in that dermatome?

                          One recommended way that the ASIA examinations is done is that one first touches the face with the cotton wisp or pinprick so that the person understands what a touch and pinprick feels like and then the examiner touches or pricks the point for each dermatome. There are tremendous differences of normal sensitivity to touch and pinprick in different parts of the body and this must be taken into account.

                          Let me study your chart and write more later.

                          Wise.

                          Comment


                            #28
                            if you use the q-tip on your face and then compare to the rest of below where I was injured, feeling my leg's will be almost non-existant. especially the back-sides of my leg's and butt. No anal sensation or contraction.

                            Comment


                              #29
                              duge, please use your common sense. The touching of the face is so that people will know what the feeling is qualitatively like. The application of the cotton wisp and the pinprick to an area of the body that is still sensitive is just to remind people what light touch and pinprick (pain) feels like.

                              If people are going to do the ASIA examination on themselves, go to their web site (and others) and read the explanation of the examination. The scoring is on a scale of 0-2 and I put some comments in parentheses.

                              0 = no sensation (numb, can't feel light touch or pinprick at all, don't know that it has happened)
                              1 = abnormal sensation (increased or decreased, you know that you have been touched but the sensation is definitely abnormal)
                              2 = normal sensation (expected for the area of the body)

                              Wise.

                              Comment


                                #30

                                Comment

                                Working...
                                X