• A 59-year-old man presents complaining of worsening pain in his left leg. He has been experiencing weight loss and lower back pain for some months.
• He has a background history of Oesophageal cancer, Obstructive sleep apnoea, Hypercholesterolaemia, Idiopathic intracranial hypertension.
• He slipped in the shower one week ago and has been able to walk since then, but now the pain is significantly worse and he is unable to do a straight leg raise.
• You arrange an XRay of his pelvis which is shown below. Comment on the X-Rays below.

What are the treatment options for this condition?

Pathological fractures

• Bone metastases to the long bones will usually lead to pain and pathological fractures.
• If it is first presentation, then a careful history and diagnostic investigations will be required such as:
  • CtScan of the chest, abdomen and pelvis- for diagnosis of primary tumour
  • PET CT- for dissemination status
  • Blood tests for evaluation of general health and fitness for anaesthetic if required
• A bone lesion with an axial cortical involvement of >30mm has a high risk of fracturing and should be managed surgically
• Radiotherapy is the treatment of choice for lesions without risk of fracturing
• The patient in this case had a prophylactic intramedullary nail inserted into his left femur

A month later………………….

• The patient developed worsening lower back pain, urinary retention and bilateral leg pain.
• An urgent MRI scan was arranged to rule out cauda equina syndrome
• Comment on the images

Further points for discussion

What is cauda equina syndrome?

• Cauda equina syndrome refers to a collection of symptoms and signs that result from severe compression of the descending lumbar and sacral nerve roots.

How does this condition typically present?

• It can present acutely or chronically, and it requires two sets of signs:

Perianal and saddle paraesthesia

Bowel, bladder and/or sexual dysfunction

• There are multiple associated symptoms and signs, which may be unilateral or bilateral.
  • Lower back pain
  • Radiculopathy
  • Paraesthesia and/or weakness of lower limbs
  • Absent reflexes

Can you think of some common causes?

• There are many conditions which can cause cauda equina syndrome. It is helpful to break them up into categories:
  • Degenerative
    • Lumbar disc herniation is most common, usually at L4/5 or L5/S1
    • Lumbar spinal canal stenosis
    • Multiple others e.g. Spondylolisthesis, Haemorrhage into Tarlov cyst, Facet joint cyst
  • Inflammatory
    • Both acute and chronic form have been seen in patients with longstanding Ankylosing Spondylitis
  • Traumatic
    • Spinal fracture/dislocation
    • Epidural haematoma (may be spontaneous, or post procedural)
  • Infective
    • Epidural abscess
    • Others e.g. Arachnoiditis, Tuberculosis
  • Malignancy- Primary or metastatic
  • Vascular
    • Aortic dissection
    • AV malformation

How is it managed?

• Cauda equina syndrome is generally a surgical emergency
• Surgical decompression within 24 hours has the best outcome
• With metastatic compression, high dose steroids, radiotherapy or intrathecal chemotherapy can also be considered, particularly when surgery is not appropriate due to frailty and other co-morbidities.