The collection of lumbar and sacral nerve roots beyond the conus medullaris has a horsetail-like appearance, from which it derives its name “cauda equina.” Compression of the cauda equina may be caused by a herniating disc (as in this case), fracture fragments following traumatic injury, tumor, abscess, or severe degenerative stenosis of the central canal.
Cauda equina syndrome is classed as a surgical emergency to prevent permanent and irreversible damage to the compressed nerve roots.
A 45-year-old man was involved in a serious car accident. On examination he had a severe injury to the cervical region of his vertebral column with damage to the spinal cord. In fact, his breathing became erratic and stopped.
If the cervical spinal cord injury is above the level of C5, breathing is likely to stop. The phrenic nerve takes origin from C3, C4, and C5 and supplies the diaphragm. Breathing may not cease immediately if the lesion is just below C5, but does so as the cord becomes edematous and damage progresses superiorly. In addition, some respiratory and ventilatory exchange may occur by using neck muscles plus the sternocleidomastoid and trapezius muscles, which are innervated by the accessory nerve [XI].
The patient was unable to sense or move his upper and lower limbs.
The patient has paralysis of the upper and lower limbs and is therefore quadriplegic. If breathing is unaffected, the lesion is below the level of C5 or at the level of C5. The nerve supply to the upper limbs is via the brachial plexus, which begins at the C5 level. The site of the spinal cord injury is at or above the C5 level.
It is important to remember that although the cord has been transected in the cervical region, the cord below this level is intact. Reflex activity may therefore occur below the injury, but communication with the brain is lost.
A 25-year-old woman complained of increasing lumbar back pain. Over the ensuing weeks she was noted to have an enlarging lump in the right groin, which was mildly tender to touch. On direct questioning, the patient also complained of a productive cough with sputum containing mucus and blood, and she had a mild temperature.
The chest radiograph revealed a cavitating apical lung mass, which explains the pulmonary history.
Given the age of the patient a primary lung cancer is unlikely. The hemoptysis (coughing up blood in the sputum) and the rest of the history suggest the patient has a lung infection. Given the chest radiographic findings of a cavity in the apex of the lung, a diagnosis of tuberculosis (TB) was made. This was confirmed by bronchoscopy and aspiration of pus, which was cultured.
During the patient’s pulmonary infection, the tuberculous bacillus had spread via the blood to vertebra LI. The bone destruction began in the cancellous bone of the vertebral body close to the intervertebral discs. This disease progressed and eroded into the intervertebral disc, which became infected. The disc was destroyed, and the infected disc material extruded around the disc anteriorly and passed into the psoas muscle sheath. This is not an uncommon finding for a tuberculous infection of the lumbar portion of the vertebral column.
As the infection progressed, the pus spread within the psoas muscle sheath beneath the inguinal ligament to produce a hard mass in the groin. This is a typical finding for a psoas abscess.
Fortunately for the patient, there was no evidence of any damage within the vertebral canal.
The patient underwent a radiologically guided drainage of the psoas abscess and was treated for over 6 months with a long-term antibiotic regimen. She made an excellent recovery with no further symptoms, although the cavities within the lungs remain. It healed with sclerosis.