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Tumors of the Spine, Intervertebral Disk Prolapse, the Cauda Equina Syndrome
Published in Jacques Corcos, Gilles Karsenty, Thomas Kessler, David Ginsberg, Essentials of the Adult Neurogenic Bladder, 2020
Patrick J. Shenot, M. Louis Moy
The physical examination may reveal a distended bladder or a positive cough test for incontinence. Examination usually shows weakness in muscles innervated by S1 and S2 (gastrocnemius, hamstrings, gluteal muscles) and sensory loss extending from the soles of the feet to the perianal region that may be variable and patchy. There may be laxity of the anal sphincter and loss of the BCR. The pattern of sensory loss restricted to the medial buttocks and perianal area is termed saddle anesthesia.
Central nervous system viral infections complicating immunosuppression
Published in Avindra Nath, Joseph R. Berger, Clinical Neurovirology, 2020
Lumobsacral myeloradiculitis syndrome (sometimes called the Elsberg syndrome) is a manifestation of reactivation or, less commonly, primary herpes simplex virus 2 infection that can occur in either immunocompromised or immunocompetent patients. Clinical manifestations include prodromal fever and headache. In one large Mayo Clinic series, sacral herpes infection was present in only 2 of 30 patients. Urinary retention, saddle anesthesia and lower limb weakness and paresthesia were present in at least half of all patients. MRI typically showed lumbar or lower thoracic T2-hyperintense signal and cord gadolinium enhancement sometimes with root enhancement [62]. Differential diagnosis includes adenovirus, VZV, CMV, vascular myelopathy, lymphoma, neurosarcoidosis, and adverse effects of treatment. As in other situations of viral infection with delay in diagnosis, highest yield of viral detection by PCR was derived from samples 3–14 days after symptom onset and demonstration of intrathecal antibody (virus-specific IgG) in CSF and serum with correction for blood–brain barrier leak using CSF/serum antibody titers proved most useful. Lesions in Elsberg syndrome tend to be more localized in distal thoracic and lumbar cord and encephalitic symptoms or longitudinally-extensive transverse myelitis would argue against HSV 2 infection and in favor of VZV or adenovirus encephalomyeloradiculitis [63].
Cauda equina injury
Published in Jacques Corcos, David Ginsberg, Gilles Karsenty, Textbook of the Neurogenic Bladder, 2015
Patrick J. Shenot, M. Louis Moy
The physical examination may reveal a distended bladder or a positive cough test for incontinence. Examination usually shows weakness in muscles innervated by S1 and S2 (gastrocnemius, hamstrings, gluteal muscles) and sensory loss extending from the soles of the feet to the perianal region that may be variable and patchy. There may be laxity of the anal sphincter and loss of the bulbocavernosus reflex. The pattern of sensory loss restricted to the medial buttocks and perianal area is termed saddle anesthesia. Smaller, less extensive disc herniation produces a more limited syndrome consisting mainly of incomplete saddle anesthesia, often combined with bladder and sphincter dysfunction. A unilateral or mild sensory deficit portends a more favorable prognosis as normal bladder function predisposes an intact visceral reflex arc of the sacral nerve roots.3,10
Giant cell tumor of the sacrum
Published in Baylor University Medical Center Proceedings, 2021
James Rizkalla, Brendan Holderread, Jonathan Liu, Al Mollabashy, Ishaq Y. Syed
Giant cell tumor (GCT) of the bone is a primary intramedullary bone tumor that comprises 5% of primary bone tumors, with sacral tumors accounting for 2% to 8% of GCT.1,2 GCT is considered a locally aggressive, intermediate-grade benign bone tumor with rare cases of malignant degeneration and systemic metastasis.3 Most commonly, it occurs in the metaphysis, with extension to the epiphysis in most skeletally mature patients.3,4 In all locations, it occurs commonly in patients between the age of 20 and 45 years and has no gender predilection.2 Patients with GCT of the sacrum may present with a history of progressive lower back pain, lower extremity pain with point tenderness, and palpable masses on physical exam.5 Symptoms may include pain, saddle anesthesia, and neurologic deficits in sacral nerve distributions.2,5 There is a paucity of literature describing this neoplasm and a lack of consensus for the management of GCT of the sacrum. The anatomical location and close relation of the tumor to nerve roots pose challenges for surgical resection. This article describes one method of treatment used for GCT of the sacrum, with discussion of other relevant surgical treatment options.
Primary epithelioid angiosarcoma of the temporal bone with initial presentation of otalgia
Published in Baylor University Medical Center Proceedings, 2018
Di Ai, Riyam T. Zreik, Frank S. Harris, Gerhard Hill, Yuan Shan
A temporal craniotomy was performed 10 days following the EAC biopsy due to progressively worsening ear pain and onset of leg weakness and saddle anesthesia. The large mass within the right temporal lobe was evacuated to lower the intracranial pressure. The mass was observed to be attached to the surface of the brain with focal invasion into the brain. Grossly, a 4.2 × 2.9 × 1.3 cm aggregate of tan-white soft lobulated fragments was removed containing brain tissue intermixed with hemorrhage. Microscopically and immunohistochemically, the tumor cells were similar to those observed in the EAC biopsy, and the diagnosis of epithelioid angiosarcoma was made. Next-generation sequencing was negative for the WWTR1-CAMTA1 fusion that is seen in epithelioid hemangioendothelioma. Following surgery, the patient's symptoms of otalgia, leg weakness, and saddle anesthesia were resolved. Postoperative positron emission tomography/CT showed a markedly hypermetabolic region of activity within the right temporal bone with extension inferiorly to involve the mastoid and adjacent extracranial soft tissues to include the right middle ear, consistent with residual malignancy. There was no evidence of distant metastatic disease. Adjuvant chemotherapy and radiotherapy were administered for 12 months. At 12-month postsurgery follow-up imaging, the disease was stable.
Intravascular large B-cell lymphoma presenting as an isolated cauda equina–conus medullaris syndrome – A case report
Published in The Journal of Spinal Cord Medicine, 2020
In a month, he was wheelchair bound and dependent on ibuprofen for pain relief. The patient also experienced erectile dysfunction without nocturnal erections and 60 lbs of unintentional weight loss at presentation. At this time, neurological exam showed decreased muscle strength and tone in his bilateral lower extremities; ankle dorsiflexion and plantar flexion were 2/5 (MRC scale) bilaterally, foot inversion and eversion were also 2/5, knee flexion and extension were 3/5, hip flexion was 4/5, and hip extension, abduction and adduction were 3/5. Knee, ankle and plantar reflexes were absent bilaterally. There was loss of cremasteric reflex and rectal tone. Sensory exam revealed saddle anesthesia to pinprick. The remainder of the physical exam was normal.