Conus Medullaris Syndrome & Cauda Equina Syndrome

Ingat!! pada dasarnya semua penyakit yg mengenai conus medullaris menghasilkan kelumpuhan UMN dan LMN, karena struktur conus merupakan bagian dari spinal cord (sistem saraf pusat) gecala dan tanda campuran UMN dan LMN. Sedangkan cauda equina merupakan nerve root atau akar-akar saraf, jadi tipe kelumpuhannya LMN.

Etiology

The most common causes of cauda equina and conus medullaris syndromes are the following:
y y

y y y y y

Lumbar stenosis (multilevel) Spinal trauma including fractures Traumatic events leading to fracture or subluxation can lead to compression of the cauda equine. Penetrating trauma can cause damage or compression of the cauda equina. Spinal manipulation resulting in subluxation has caused cauda equina syndrome Herniated nucleus pulposus (cause of 2-6% of cases of cauda equina syndrome) Neoplasm, including metastases, astrocytoma, neurofibroma, and meningioma; 20% of all spinal tumors affect this area Spinal infection/abscess (eg, tuberculosis, herpes simplex virus, meningitis, meningovascular syphilis, cytomegalovirus, schistosomiasis) Idiopathic (eg, spinal anesthesia ): these syndromes may occur as complications of the procedure or of the anesthetic agent (eg, hyperbaric lidocaine, tetracaine) Spina bifida and subsequent tethered cord syndrome

Table 1. Symptoms and Signs of Conus Medullaris and Cauda Equina Syndromes Conus Medullaris Syndrome Vertebral level L1-L2 Presentation Sudden and bilateral Reflexes Knee jerks preserved but ankle jerks affected Radicular + pain Low back pain +++ Symmetry of Usually symmetric symptoms and signs Sensory Numbness tends to be more symptoms and localized to perianal area; signs symmetrical and bilateral; sensory dissociation occurs Cauda Equina Syndrome L2-sacrum Gradual and unilateral Both ankle and knee jerks affected +++ + Usually asymmetric

Motor strength

Impotence

Numbness tends to be more localized to saddle (bokong dan perianal) area; asymmetrical, may be unilateral; no sensory dissociation; loss of sensation in specific dermatomes in lower extremities with numbness and paresthesia; possible numbness in pubic area, including glans penis or clitoris Typically symmetric, Asymmetric areflexic paraplegia that is hyperreflexic distal paresis of more marked; fasciculations rare; atrophy lower limbs that is less marked; more common fasciculations may be present Frequent Less frequent;

Sphincter dysfunction

Early and severe bowel, bladder, Urinary retention and atonic anal sphincter cause overflow urinary incontinence and fecal incontinence; tend to present early in course of disease Mostly normal lower extremity with external anal sphincter involvement The outcome may be less favorable than in patients with CES

Urinary retention; tends to present late in course of disease

EMG

Multiple root level involvement; sphincters may also be involved May be favorable compared with conus medullaris syndrome

Outcome

NOTES: y y Hyperactive reflexes, Babinski sign or other signs of upper motor neuron involvement may signal spinal cord involvement and exclude the diagnosis of cauda equina syndrome. Pain radiating to the leg is characteristic of cauda equina syndrome associated with radicular sensory loss (saddle anesthesia), asymmetric paraplegia with loss of tendon reflexes, muscle atrophy, and bladder dysfunction In conus medullaris syndrome, the sacral region neurons (S2-S4) are destroyed leads to an early and more severe involvement of bowel, urinary bladder, and sexual dysfunction than seen in those with CES.