Elsevier

World Neurosurgery

Volume 144, December 2020, Pages e643-e647
World Neurosurgery

Original Article
Intracranial Mimics of Cauda Equina Syndrome: Heads or Tails?

https://doi.org/10.1016/j.wneu.2020.09.014Get rights and content

Background

To report cases of extraspinal mimics of cauda equina syndrome (CES) to enable prompt diagnosis and treatment in the future.

CES results from compression of spinal nerve roots. Current practice mandates lumbosacral magnetic resonance imaging (MRI) scanning to diagnose CES. However, it may not reveal compression or provide an explanation for the presentation. We present 3 cases of suspected CES who went on to have intracranial pathology.

Methods

Retrospective review of all patients presenting with CES-type features who were subsequently found to have causative intracranial pathology over a 6-month period.

Results

Three cases were found, and these are hereby presented. Case Presentation: Case 1: A 57-year-old lady presented with urinary retention and bilateral leg weakness. She underwent an MRI spine which showed no evidence of CES. She was diagnosed with haemorrhagic intracranial metastases. Case 2: A 52-year-old lady presented with lower back and right buttock pain, with right-sided leg numbness, saddle hypoesthesia, and bowel and bladder incontinence. MRI spine showed no cauda equina compression. MRI neuraxis revealed a subdural haematoma. Case 3: A 69-year-old lady presented with a 6-day history of urinary incontinence, right foot drop, and leg weakness. MRI spine was negative for CES. She was diagnosed with an intraparenchymal haematoma of posterior left frontal lobe.

Conclusions

Negative lumbosacral MRI will not exclude extraspinal mimics of CES and, although rare, these cases should be considered.

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.

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