eMedicine Specialties > Neurology > Introductory Topics

Cauda Equina and Conus Medullaris Syndromes: Follow-up

Author: Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed), Former Clinical Instructor, Mount Sinai Medical School; Current Director, Pain and Injuries Rehabilitation Services, PMRehab Pain and Sports Medicine Associates
Coauthor(s): Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Contributor Information and Disclosures

Updated: Feb 10, 2009

Follow-up

Further Inpatient Care

  • Rehabilitation - Physical therapy and occupational therapy for muscle strengthening, endurance, mobility, activities of daily living, gait/balance, use of assistive devices, and adaptation to home environment
  • Surgical follow-up for postoperative spinal care, depending on the cause
  • Urology4 - Cystometrography to define bladder pathology (Patients should undergo regular follow-up on discharge for any renal or bladder complications and impotence, because they have an increased tendency for recurrent urinary tract infection and calculi.)
  • Dietitian

Further Outpatient Care

  • Follow-up with consulting physicians within a week after discharge
  • Follow-up with a primary care physician to monitor posthospital medications and other laboratory tests
  • Yearly cystoscopy for patients with suprapubic catheters to help detect early bladder malignancies
  • Regular follow-up urodynamic studies, renal ultrasound, and general cancer screening
  • Follow-up with the rehabilitation team, including the spinal cord injury rehabilitation physician, physical therapist, and occupational therapist. These professionals are responsible for monitoring community and home integration and following improvements in the patient's strength, coordination, transfer, activities of daily living, and ambulation.

Inpatient & Outpatient Medications

This includes continuation of anticoagulation medications (if necessary), antispasticity medications, and other medications being given to ameliorate possible complications, including bladder and bowel problems and heterotopic ossifications. If a patient is on warfarin, one of the team physicians looking after the patient must be designated to monitor the international normalized ratio (INR) at regular intervals.

Transfer

On discharge from the surgical ward, patients often are transferred to an acute rehabilitation unit, from which they may be discharged, transferred to a subacute unit, or transferred to long-term care depending on the level of long-term disability.

Complications

  • Thromboembolic phenomena
  • Neurogenic bladder/bowel
  • Erectile dysfunction
  • Pressure ulcers
  • Heterotopic ossification
  • Osteoporosis
  • Chronic neuropathic pain
  • Spasticity/contractures
  • Recurrent urinary tract infections
  • Urethral stricture
  • Bladder calculi
  • Depression

Prognosis

  • Prognosis can be predicted based on the ASIA impairment scale.
    • ASIA A: Ninety percent of patients remain neurologically complete and unable to have functional ambulation.
    • ASIA B: Seventy-two percent of patients are unable to attain functional ambulation.
    • ASIA C/D: Thirteen percent are unable to attain functional ambulation (reciprocal gait of 200 feet or more) 1 year after injury.
  • Ambulatory motor index also is used to predict ambulatory capability, it is calculated using a 4-point scale (0=absent, 1=trace/poor, 2=fair, 3=good or normal) and then calculating hip flexion, hip abduction, hip extension, knee extension, and knee flexion on both sides; the score is expressed as a percentage of the maximum score of 30.
    • A score of 60% or more shows a good chance for community ambulation with no more than one knee-ankle-foot orthosis (KAFO).
    • A patient with a score of 79% or higher may not need an orthosis.
    • A patient with a score of 40% or less may require 2 KAFOs for community ambulation.

Patient Education

  • Training in self-catheterization and finger fecal disimpaction, if required
  • Use of measures to prevent pressure ulcers, such as skin inspection/care, positioning, turning and transferring tactics, use of skin protectors, or pressure-reducing support surfaces
  • Maintenance of endurance and strength-training exercises
  • Regular follow-up by the consulting teams who treated the patient in the hospital
  • Instructions on how and when medications should be taken and when follow-up laboratory tests should be performed
  • For excellent patient education resources, visit eMedicine's Erectile Dysfunction Center and Brain and Nervous System Center. Also, see eMedicine's patient education articles Impotence/Erectile Dysfunction, Erectile Dysfunction FAQs, and Cauda Equina Syndrome.

Miscellaneous

Medicolegal Pitfalls

  • Physical examination for cauda equina or conus medullaris syndromes would be incomplete without tests for sensation of the saddle and perineal areas, bulbocavernosus reflex, cremasteric reflex, and anal sphincter tone, findings for all of which are likely to be abnormal.
  • MRI with gadolinium contrast of the lumbosacral area is the diagnostic test of choice to define pathology in the areas of the conus medullaris and cauda equina. Plain x-rays and CT scan may be normal.
  • Conus medullaris infarction should be considered in the differential diagnosis, and a source of emboli should be sought by ultrasound to rule out an abdominal aortic aneurysm.
  • HO should be ruled out by triple-bone scan in a patient with pain and swelling of the lower extremity in whom deep venous thrombosis (DVT) has been ruled out. In other words, HO should always be considered as a differential diagnosis of DVT in these patients.
  • Spinal, metastatic malignant neoplasms should be ruled out and the primary source sought as part of the workup in any patient presenting with any of the symptoms listed in Clinical.
 


More on Cauda Equina and Conus Medullaris Syndromes

Overview: Cauda Equina and Conus Medullaris Syndromes
Differential Diagnoses & Workup: Cauda Equina and Conus Medullaris Syndromes
Treatment & Medication: Cauda Equina and Conus Medullaris Syndromes
Follow-up: Cauda Equina and Conus Medullaris Syndromes
Multimedia: Cauda Equina and Conus Medullaris Syndromes
References
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References

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Further Reading

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Keywords

lower spinal cord injury, compressive lumbosacral polyradiculopathy, cauda equina syndrome, conus medullaris syndrome, spinal cord compression, back pain, spinal cord injury, upper motor neuron symptoms, UMN symptoms, lower motor neuron symptoms, LMN symptoms, spinal cord syndromes

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Contributor Information and Disclosures

Author

Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed), Former Clinical Instructor, Mount Sinai Medical School; Current Director, Pain and Injuries Rehabilitation Services, PMRehab Pain and Sports Medicine Associates
Segun T Dawodu, MD, JD, MBA, FAAPMR, FAANEM, CIME, DipMI(RCSed) is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, American Medical Association, American Medical Informatics Association, Association of Academic Physiatrists, International Society of Physical and Rehabilitation Medicine, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

Medical Editor

Milind J Kothari, DO, Professor and Vice-Chair, Department of Neurology, Pennsylvania State University College of Medicine; Consulting Staff, Department of Neurology, Hershey Medical Center
Milind J Kothari, DO is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

James H Halsey, MD, Professor, Department of Neurology, University of Alabama Medical Center
James H Halsey, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neuroimaging, Medical Association of the State of Alabama, New York Academy of Sciences, Pan American Medical Association, Sigma Xi, Society for Neuroscience, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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