Original ArticleIntracranial Mimics of Cauda Equina Syndrome: Heads or Tails?
Introduction
Cauda equina syndrome (CES) results from compression of spinal nerve roots, most commonly from a herniated lumbosacral disc.1 It is classed as an emergency and requires prompt diagnosis and treatment. Current practice mandates urgent lumbosacral magnetic resonance imaging (MRI) scanning to exclude neural compression and to plan surgery.2,3 However, most such scans do not reveal compression of the cauda equina or provide a radiologic explanation for the presentation, for example, demyelination, infective, or inflammatory spinal causes.2 We present 3 cases of suspected CES who had normal lumbosacral MRI scans but went on to have significant intracranial pathology diagnosed during their inpatient stay. This includes 1 case of cerebral metastasis, 1 spontaneous intraparenchymal hemorrhage, and 1 subdural hematoma. Although no patient deteriorated as a result of their intracranial pathology, timely diagnosis may have prompted referral to specialist services and definitive management sooner.
Section snippets
Case 1
A 57-year-old female patient known to have melanoma metastatic to lung presented with painless urinary retention and bilateral, symmetrical leg weakness (Medical Research Council 2/5 power hip flexion, 4/5 others) that developed over the preceding 12 hours. Of note, she denied any headache or back pain. In view of lower-limb weakness and urinary retention, CES was appropriately considered.
She underwent emergency MRI of the whole spine and this revealed minor degenerative spondylosis (Figure 1)
Discussion
We present 3 cases of intracranial lesions mimicking CES. It is only safe to exclude CES by having a low threshold for emergency MRI of the spine—clinical examination alone has a notoriously unreliable negative predictive value here.4,5 Although only a small proportion of patients will have demonstrable organic pathology,6 when MRI of the lumbosacral spine does not explain presenting features, alternative causes should be considered.7,8 There is a tendency to look for features consistent with a
Conclusions
In patients in whom acute CES has been ruled out through a negative lumbosacral MRI, it is important to exclude causes that may be mimicking the syndrome. A history and examination that are atypical should warrant further imaging to rule out intracranial pathology.
CRediT authorship contribution statement
Ashwin Kumaria: Conceptualization, Methodology, Writing - original draft, Writing - review & editing, Project administration. Zulfiqar Haider: Resources, Writing - original draft. Arousa Ali: Software, Writing - original draft, Project administration. Dilip Pillai: Resources, Project administration, Validation. Raj Bommireddy: Conceptualization, Supervision. Antony Bateman: Supervision, Validation. Harinder Gakhar: Supervision, Formal analysis.
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.