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I'm going to talk about Cor Quina Syndrome, which I realize is very exciting, but it's something you will need to know about. Uh, no matter where you work as registrars, it'll be sort of ticking through it all. Um, uh you'll always see the query corner and then if you're working in D DH S, you'll see them as well. Um But also you need to know about it for the exam. So I'm gonna try and do a sort of, we're gonna talk about the signs and symptoms, the role of surgery and also how patients do after Corinna. Um And then we're also gonna talk a little bit about some of the other less common causes that we find with Cor Quina and also why it happens and what's actually going on. And II I want to try and do a balance between what you need for the exam, but also things that will help you clinically. So bear with me and I'll try and get through it pretty quickly. Um So qui it, I'm sure you all know it's the horse's tail described by uh LASA back in 1600. Um And it's all that motor innervation, going down the legs, going to the sphincters, to the bed, to the uh bladder and also to the saddle area. Um, and it's, it's essentially nine pairs of nerve roots going from L2 down. It includes the coccygeal nerve root, um, and S five. And it's important for you guys to know the bladder supply, the bladder's nerve supply. So what the parasympathetic bit does and what the sympathetic does. So, in the parasympathetic promotes urination, contracts the muscles and relaxes the, the sphincter and the sympathetic promotes urine retention by relaxing the muscles and um contracting the internal sphincter. And so those two, those two are very important to remember, um, because often when you get the damage that's associated with Cordo quina, it can be a slightly mixed picture of this. So when patients go and see the urologist when they've had their Cordo Quina syndrome and they do their bladder studies, they'll find a mixed picture of overactivity. We always think when I certainly did, when I was a registrar that it was just that they had no sphincter control and they'd just be wetting themselves. But it's not, it's a really mixed picture of parasympathetic and sympathetic problems that causes their urinary symptoms. Um, so the actual syndrome itself was first sort of properly recognized in 1934. And one of the problems with Cord Quina syndrome is that it's very, very variable. Um, in how it presents, er, you really to try and pick, put one thing down as that of how it presents is very, very difficult and also it can present in quite a varied manner. There is a classic picture, but that classic picture is actually quite a small percentage of it. Um, and this is probably the reason it's the most litigated spinal condition. So, um, 23% of spinal ah litigation claims in the UK are about cord quina syndrome and it's higher in the in the US. And these cases play very, very high. So the last case from Norwich where there was an alleged miss from a physio three weeks before the patient actually developed Cor Aqui Syndrome, um resulted in a 1.5 million payout for somebody who had no bowel or bladder dysfunction but was unable to achieve orgasm. So, you know, the amount of money involved is staggering. And so it, it typically it's Cor Cor snd is caused by any sort of compression to the nerve roots below the Conus meal medullaris. It is slightly different to a Conus lesion. Um uh and anything that occupies the canal can cause um this to happen. Um you can have problems that can make you more susceptible to having a Corinna picture, um uh even causing it. So for example, people have different canal diameters. There are people that can have hereditary hereditary, narrow canals and a small disc bulge for them can be far more devastating than someone who has, for example, you know, er, some people congenitally have a very broad canal or even if they've got something like neurofibromatosis have a massive canal because of all the scalloping and it takes more disc material than they've actually got in their nucleus PSIS to cause a corner syndrome in the same breadth. If somebody has significant spinal stenosis due to thickening of the ligamentum flavum, um, then actually only, you know, only a tiny little if they've got say one facet joint cyst and they beat into that cyst, that can be enough to tip them over the edge. Um So presentation is, I think you guys will all know all of this. But what I've put down here are what, what the, the most recent thing from guff um and bas and SPNS and all the neurosurgical and spinal societies tells us. So I'm just checking. Um So they have, this is what they say. So anybody that has leg pain or back pain with any recent onset difficulty peeing or not being able to feel their, their bladder altered perineal uh genital sensation um and then severe progressive deficits in both legs, so weakness um or loss of sensation of their rectum being full and then sexual dysfunction. And so that's a pretty broad spread of categories and it can be a mixture of any of those. And I'm sure you'll all know from your times on call as to what people come in to come in with and their ability to, to cry wolf. Um And then you sort of look at the most common signs. So the most common symptom is back pain and that's in uh nine out of 10 people presenting with Corinna syndrome. But the most consistent sign is the urinary retention. And then anal sphincter tone can be very diminished in nearly three quarters of these patients. And there's also sad anesthesia in three quarters of these patients. But those are all very subjective um, signs testing anal sphincter tone, there's a difference between the anal sphincter tone that you would expect in an 80 year old lady and a 60 year old um, er, lady and a 40 year old lady. But there isn't any real sort of ability to qualify that in any way at all. And what I would say to you is if you've ever done APR on someone who's had a fullblown spinal cord injury with complete absence of anal tone, you will realize what complete loss of anal tone is compared to what we see with these patients that come in with slightly gray hazy symptoms. Um, but uh you know, low back pain is very nonspecific. Um and in quarter quina, you rarely get new back pain without the other symptoms being around. Um, and then go to also say that, you know, the sudden onset of pain going into both legs or a sudden onset change from unilateral leg pain to bilateral may be a, a warning that they're gonna get quina. Um which is, I think is very true, but also the number of patients that come in with leg pain, um that has nothing to do with the qu qu, the bilateral leg pain, we know that's very high as well. Um quad quina tends to come on very acutely. Um And the majority of people have had some sort of preceding history of back pain, they've had some problems going on. Um, you do sometimes see people who've got an acute cord quina who've never had any back pain, never had any sciatica. But there tends to be a sort of preceding period of time where there's something going on with their discs, something going on with their back that makes them slightly more vulnerable and then they do something that tips them over the edge. Um, if it has a slow onset and it's quite gradual, that does happen. We do see that, but that's normally associated with firstly, with a different pathology to, to the typical herniated disc. And also those are the ones that tend to have a better chance of recovery if they're treated. So, the incidence, yeah, of Corder Equina syndrome is rare. It's 111 between one and three per 100,000 people, but about 2% of people that have surgery for disc prolapses are having it done for Corder Aqui Syndrome. So why, why does it happen? Why when we get this compression of the nerve roots, what happens? So when you, if you've ever seen somebody doing a dural tear, um, so obviously not anyone that's ever operated with me. Um But if you've ever seen somebody getting a dural tear and you see that spaghetti coming out, those nerve roots are very thin, they're very wiggly, they're very wormy and they, you know, you compare that to what you see when you do a carpal tunnel or when you find the radial nerve in the, in the arm. And you know, it's very different. And so it's lacking the epineurium and, and, and the perineurium almost and it's just pretty much protected only by the endoneurium. So um there isn't as much protection for these nerve roots. And so they're much more vulnerable to compression and to tension and to shear. And they're also because they don't have the Epineurium, they have a much poorer blood supply and they get a lot more of their oxygen and they release their carbon oxy and what have you by permeation from the CS F, which is great because it deals with the fact they have a, a good blood supply, but it means they're much more vulnerable to edema, especially if there's a whole load of uh chemical mediators released. But in which you do get in the process of a disc prolapse. Um So you get effectively a compartment syndrome within the nerve and you get that venous congestion, the edema, which I've just mentioned, um and then that all combines to further decrease the perfusion pressure coming through. So when you think about compartment syndrome in the leg and how it's almost a propagating event, um it's a similar thing in the nerves. And so the nerve roots die from ischemia. And the reason that the sacral nerve roots are particularly susceptible to this is because they're that much smaller. But also because you've got those parasympathetic sympathetic um fibers which are unmyelinated. So they're even more susceptible to compression. Um And so they can achieve that they can get to that ischemic tipping point much faster than say, you know, if you press on the L5 maneuver, you can leave it compressed with a disc prolapse for months, especially, you know, and you know, until you, until you operate on it and, you know, you've still got that 85% chance it's going to come back. Um Animal models have shown us that um it's the pressure threshold is pretty low, it's 55 to 75 millimeters of, of mercury and um er, and only greater than two hours of that produced irreversible nerve damage, but it's also to do with the speed of the compressive insult. And so I'm sure you've all looked at scans of people with spinal stenosis where it's tight as a NAS chap. I mean, there is no room for the nerves whatsoever, but those patients don't have corner syndrome yet somebody can have a disc prolapse and you can think, oh, there's still a bit of room there, but they've got corner syndrome and we think that the reason is due to the, the rapidity of the onset of the compression. So even making it less than naught 0.1 of a second versus 15 seconds, you get a different, a significant differential in how edematous the nerve root gets. And that's so that's 15 seconds. Whereas if someone's developing stenosis over five years, you can see why their nerve roots accommodate and they don't get the traumatic response that you get in Cor Aquinas syndrome. So, disc herniation is the most common cause 45% of uh quad aqui cases. And as I said, 2% of lumbar disc prolapses. Um and it can be anywhere in the lumbar spine and the most common level being L4, 5 and then L5 S one and how it presents will vary according to the level of the disc prolapse as to where they get that pain. Um And what symptoms they get. Um The other thing you have to think about is whereabouts in the canal that the, the prolapse actually come actually comes in because if it's a very central prolapse but and very sort of almost coming out like a, I don't know how to describe it. A minion, maybe, I'm sorry, my brain's still in kid mode. It holidays. Um Then it's gonna get central compression, you're gonna get compression of those sacral nerve roots. But the s one nerve roots may be completely left alone. And so they don't have the leg pain, they don't have and they even have normal ankle reflexes because um actually it's only compressing the sacral nerve roots. Um And so, you know, you have to think about, whereas if it's up at L2, 3, it'll present in a slightly different way and they may have more profound leg symptoms and less obvious sacral nerve root symptoms. Um The most common group of people for get to get disc prolapses is men between 30 40 who've had previous back pain and the majority of those have got a virgin spine that's never been touched before. So other things that can cause um compression. So metastatic tumors can cause a direct compressive effect. So we're talking about extra dural compression here, we're talking about things outside the jura that can push on there. Um They can also tumors can also cause it either through a direct compressive effect or through a pathological fracture. So you can see here, you can imagine that's a tumor. So it's myeloma coming out the back there or lymphoma and it's just causing canal compression. But you can also get a pathological fracture with retropulsed bits of bone and tumor protruding into the canal. So this kind of falls between metastatic cord compression, but it's not metastatic cord compression it's metastatic cord quina, but it's just as serious and it requires just as much treatment as any other called quina. Sometimes the onset is slower, say in a direct compressive effect, you get a slower onset. Whereas in a um in a pathological fracture, you're gonna get a sudden onset where it just goes. And so going back to the previous animal models and the evidence, you know, the, the patient where they have a pathological fracture that suddenly quina may do far worse than the person who has a direct uh has a sort of gradually creeping compressive effect. Um Lung is the most common sort of non cranial uh non CNS tumor that uh will cause uh cor aqui. But you've also got to remember that it's still rare. So quina only, it occurs in less than 1% of people who've got metastatic lung cancer that has spread to the spine, not all metastatic lung cancer, but of all the cases where you get lesions within the spine, less than 1% of them will have Chona syndrome. Um CNS tumors will ca can cause this. Um So you can get drop metastases from oh sorry, intracranial should be intracranial. I apologize, ependymoma and Germon. Um and they cause seeding as they drop down from the CS F space. And again, you're going to have a very different history. You, you often have preceding symptoms and warnings um that the patient will have been aware of before they present with this. And it's more of an intradural pressure effect. So it's, it's effectively swelling out from within the jura causing the compression. Um, primary tumors are as rare as tend to is the only way I can describe it. Um the primary tumors that you get down at the ph terminale in the corder aqui. So 90% of them are ependymoma and of those 60% of the mix of papillary subtype, which are the very invasive ones that cause the badness. Schwannoma can cause a direct compressive effect. But again, that's going to be slow growing and chordoma can cause it as a primary tumor, but that's a bit of a cheat because it tends to be through the sort of sacral bone destruction and the pathological fracture element. So I guess it's more like a metastatic presentation as opposed to a primary tumor. Um Trauma obviously can cause it as well. Um It can either be a direct disruption um through a dislocation or a subluxation um or through a hematoma formation. And it, it's a bit tricky. The incidence of Cor Quina Syndrome in trauma is difficult to pin down because excuse me, often, there's so many coexisting injuries and a dislocated spine at L4. I guess you could call that a Corinna Syndrome, but it's more of a cord injury even it's below the spinal cord other causes. So spinal epidural hematomas, these can be iatrogenic, it can be from sort of a needle going into the spine. It can be from, you know, quite aggressive. Um you know, treatment with heparin for a pe infection can either cause it through pass or an epidural collection or through bony destruction. And essentially anything that you can think of that may cause space occupying within the cord quina is going to cause compression. But when you're asked in the exam, you know, it's the disc first of all before and then it's metastatic disease. And then the rest of it, as you say that you can say they're all rare as hen's teeth, but you can just work down the list. Um So I'm gonna talk briefly moving on to management and I'm gonna come back to this slide but this slide is from the GF guidelines that were produced um earlier this year. Um But what I want to say is that how we manage Chord Quina syndrome is driven by the outcomes of the interventions and the timing of the interventions. And all of that relies on establishing the diagnosis. Um So you've done your history, you've done and you've done your examination. But the MRI standard is the gold, the MRI gold standard for uh for Qu Qu syndrome. And the newest guidelines are that it should be done within four hours from the referral from with the, with the, from Ed and in the UK, this is what we're going to have to stick by. This is the yard stick by which we're gonna be measured. And so I think it's very important that you guys read those Gulf that GFF um guideline and familiarize yourself with it because that's what the answer will be in the exam. And the MRI, interestingly GFF say is a minimum of a, of a T two sagittal um lumbar scan, but I wouldn't take anyone to theater without axial views. And the radiologists here have agreed that as well. Um if they can't have a, an MRI scan for a pacemaker or something along those lines, then a CT or a CT myelogram uh will give you information. It's not as good, but you have to have some sort of imaging. Um bladder scans are recommended um but not if they're going to delay things. And you've got to remember that your post void residual is normally between 50 to 100 mils. Um And if they've got less than 200 mils, then it's a n 97% negative predictor value for Qu Qu syndrome. But you cannot use a bladder scan, a negative bladder scan or well emptied bladder. Um As a discriminator against cord a Quina syndrome, you have to take everything else into account if the history and the examination is otherwise predictive of Corder Aquinas syndrome, then they're going to need investigation. Um So g to say that doing a APR is not necessary. Um but you need to record the perianal sensation. It is. And I think one of the reasons for this is that, as I said earlier on measuring anal tone, the voluntary involuntary squeeze is, is, is very subjective and patients will, can repress it to a degree as well. What they can't repress is the Barbo cavernosa reflex. And there are some papers that almost put the sensitivity and specificity of the Barbo cavernosa reflex, which will tell you how intact your sacral nerve roots are um as as almost 100%. But the reality is that it requires a catheter and it's very, and that's not there. And again, putting a catheter in will delay the diagnosis. And so GF don't even fit it into their role. So we then talk about the classification of quina and this is very, again, very varied, which probably relates back to how varied the presentation is, multiple studies uh looking at qu Qu and only 16% of them had some form of form of definition. So there's the bass definition, which is the two stage system where you've got the incomplete Qu Qu syndrome versus the Qu Qu syndrome where they've got complete bladder retention. Um There's the fraser and then there's the Glee and mcfarlane um uh classification and the bas one, the two stage one is the most commonly used and that's because it has a prognostic value. Um So, actually, classifying Corde Coin Syndrome is not as simple as one would hope. Um So it's all a little bit wooly really, isn't it? And I think that defining where a patient is, are they c si are they CS R is, is, is, is very difficult. And I think that's why there's so much litigation about it. So, uh there's a bas paper which I thought showed some useful pictures which I thought I'd tell you guys about. So, so Corder Aqui syndrome suspected if you like. Um, so a patient presenting with bladder irritability for 24 hours, three weeks of low back pain, leg pain over the lateral aspect of the shin. Um And they come in with, you know, that bladder irritability, they have an MRI scan shows a far lateral disc and um and the graph, this is what their symptoms look like. So they get a sort of gradual increase and then the and then full recovery, their bladder symptoms is expected, whereas incomplete looks a bit like this. So this is somebody with three weeks of back pain, bilateral leg pain for one week, 12 hours of bladder irritability and altered peron sensation on examination. So they've got a lot more to their history that you would worry about. They have an MRI scan shows a large central disc prolapse corinna compression. And so they've got an incomplete quad picture. So given the fact that they've got a positive MRI scan surgery is undertaken rapidly and the expectation is that their symptoms are going to recover. Um So, and the timing of surgery really is where along that curve are they, um, uh, as to whether you're going to get a good response and then you've got complete or CSR. And so this is the worst case scenario. A patient who presents with a three day history of bladder leaking bladder incontinence can't feel their bladder filling. They've got a painless urinary retention, loss of peral sensation and loss of perianal tone. And the MRI scan shows a massive disk prolapse. Um And so this patient still goes to theater. Um But you don't expect them to get a lot of recovery and they have a long term bladder dysfunction as a result of it. Um So the prognosis depends on the diagnosis where they are along that, that curve. Um And so some studies suggest that there is a time dependence to it. So, Shapiro back in 2000 said in their, in their study in the states that 95% of people recovered continence and normal function within six months if they were operated within 48 hours of symptom onset. But what symptom are you talking about? You're talking about the back pain, the leg pain, the bladder, the incontinence, you know, it's very, as I said, it gets, it's still wooly. Um Whereas 63% of those whose surgery was delayed beyond 48 hours still required catheterization. So generally they get their pain gets better. Their motor function improves. But the autonomic ones those very s um, fragile nerves that I talked about are the last ones to get better. Um, but then another meta-analysis in 2000 of 332 332 patients again, showed this recovery within 48 hours and the lawyers became fixated on this and this became the stick with which the spinal, er, world got beaten, er, with their legal, um, legal. Yeah, legally. And um, yet other studies have shown that actually there's no difference. So mccarthy showed that there was no improvement at all, regardless of the time of surgery after the onset of symptoms. And it's more about whether they are complete or incomplete, um, when they're operated on. Um, and then the most recent thing which I think a lot of the, um, GF stuff is based on was a, as a Multicenter study, uh, published last year, which is worth casting your eye of at least the, um, the abstract for which was done in the UK, 636 patients and two, sorry, 621 patients. And I think the thing to take away from this is that, uh, oh, hold on, er, is that, um, catheter requirement and their outcome score? So their, a disability index was associated with the presentation but neither outcome was associated with time to surgery or radiological compression. So, surgery timing to surgery didn't seem to matter. Um, to these 621 patients but another. Um but there is no association but significant health care needs remain postoperatively. So 65% of these patients are struggling after surgery, irrespective of whether they were CE SI or CSR. And they do qualify this statement about the timing by saying that because 90% of the patients actually were operated within a day of coming in. They can't really say whether their outcomes are worse or not because this is an observational study and you can't really do a randomized controlled trial of these patients. Um, so you could say that the outcome is inversely related to the time from symptoms of surgery, but it's very difficult to pick a time when that outcome changes because the, um, because qui is, is so variable, so hetero heterogenous. Yeah. You know the word. So this is why it's the bane of our existence because we, er, these are the ones you hate to get when you're on call because they're the ones in the gray area. The ones who are, can be the repeat offenders who can keep talking the talk and saying the right things. And the reality is that we all now practice very defensive medicine. Um, in some ways, the lawyers have won the willingness around the definitions of Quina gives them all the room they need, um, legally. And so, you know, given how we practice in the UK, I can only imagine how defensive it must be in the states where they have no crown indemnity. Um, but in the UK, we've got those guidelines to fall back on and that's really our safety belt. So as long as those are followed, then we should be ok. But it's the willingness that leads to the problem. But the thing is I've seen you any, pretty much anyone with back or leg pain or a hint of any sort of urinary or coral type symptoms gets a scan. Um So it's a very non clinical way to manage things, but I suppose 1.5 million lbs pays for a lot of MRI S. Um So management G these are the GF guidelines do look them up. Um And it's a very detailed outcome and each bit has um a click box on, it will lead you on to more information. But one of the things that I think is very sensible is that ed can request MRI scans. And so orthopedics or neurosurgery only get involved once the diagnosis has been confirmed. Finally, the light is there. That's what we were doing in Australia when I was there on fellowship 10 years ago. And it's about time that happens here because hopefully we can avoid the admission and um uh unnecessary admission and the scanning, you know, and the, so the that decision is taken out of orthopedics hands and it's quite clear in how it should happen. Um So when to operate. Um So this is again, a slightly gray area. Should we be operating in the middle of the night? Uh, the study that I mentioned about the 621 patients done in the UK, found that patients were operated on the middle of the night by neurosurgical registrars in neurosurgical centers but otherwise were not operated in the middle of the night. Um, so it's, you know, timing for surgery is at the discretion of the operating surgeon. Um, once they've got ac uh, an established Qu Quina syndrome, they should still be, uh, still have surgery but there's less pressure there. Um, so how to operate, I don't think, I don't, I'm not gonna go to tell you guys about the exact nature of the operation, but suffice to say that you can either do a complete laminectomy, you can do a hemilaminectomy or a laminotomy and they're all acceptable as long as you get, uh, the, the material out, they're not easy operations and they have a much higher complication rate than elective disc operations. And so they should always be supervised. And again, this is, this is what you have to say in the exam. Um, and so postoperative management. So the first thing is the bowel and bladder care, um, it's very important that they have the right sort of training to look after their bladder. And we're very lucky at the Norfolk nor we've got two fantastic urology consultants who run a neuropathic bladder clinic and they they tell us that, you know, the minute somebody fails to talk, the catheter should go back in because the long term damage from a neuropathic bladder trying to work is much worse than if they have a catheter. And they're taught to do the right things. Um, the other thing they need a lot of input for is for their sexual function and also their psychological input and they also need to be followed up. These patients can't just be discarded and left because they need a lot more support than uh than the normal sort of disc prolapses. So in summary, um cord quina syndrome is very rare if it's genuine, it's the suspected Cordo quina is very common and it's very variable and it's very difficult to define. So stick to those vast definitions when you're talking about it in the exam. But as you know, in reality, it's a massive spectrum but it, it, it ruins patients lives. They will have a lifetime of self catheterization of having to manually disimpact their feces. So it isn't something to miss, not just because of the legal implications, but just because of the personal implications to each patient. Um and follow the guidelines, follow the guidelines from G in the exam and follow the guidelines when you're practicing as a registrar or as a consultant. OK. Excell.