cauda vs conus

The spinal cord ends between

the T12 and second lumbar
vertebrae in an average adult.
The most distal part of the
spinal cord is called conus
medullaris, The upper
border of the conus medullaris
is often not well defined.
Distal to this end is a
collection of nerve roots, which
are horsetail-like in
appearance called cauda
equina connection
between (CNS) and (PNS).
Conus medullaris -
constitutes the distal part of
the cord and is in proximity
to the nerve roots. Thus,
injuries to this area often a
combination of UMN
and LMN symptoms and
signs in the dermatomes and
myotomes of the affected
segments.
Cauda equina lesion is a
LMN lesion because the
nerve roots are part of the
PNS.
Signs of cauda equina syndrome :
Muscle strength and tone(LMN) in the lower extremities
is diminished.
Sensation is decreased to pinprick and light touch
corresponding to the affected nerve roots. This includes
saddle anesthesia ,glans penis or clitoris and decreased
sensation in the lower extremities. Vibration sense may
also be affected.
Muscle stretch and Babinski reflexes may be absent or
diminished .
Bulbocavernosus reflexes may be absent or diminished.
Anal sphincter tone is decreased can define the
completeness of the injury and useful in monitoring
recovery.
Urinary incontinence occur secondary to loss of urinary
sphincter tone; may present initially as urinary retention
secondary to a flaccid bladder.
Signs of conus medullaris syndrome :
Patients may exhibit hypertonicity, especially if
the lesion is isolated and primarily UMN.
Almost identical to those of the cauda equina
syndrome, except that in conus medullaris signs m
likely to be bilateral;
Sacral segments occasionally show preserved
bulbocavernosus reflexes and normal or
increased anal sphincter tone;
Muscle stretch reflex may be hyperreflexic,
especially if the conus medullaris syndrome (
UMN lesion) is isolated; Babinski reflex may
affect the extensors; and muscle tone might be
increased ( spasticity).
Distended bladder due to areflexia.
 Conus Medullaris Syndrome Cauda Equina Syndrome

Presentation Asymmetric areflexic Typically symmetric, hyperreflexic distal

paraplegia that is more paresis of lower limbs that is less
marked; fasciculations rare;
atrophy more common
marked; fasciculations may be present

Vertebral level T12-L2 L2-sacrum

Spinal level Injury of the sacral cord Injury to the lumbosacral nerve roots
segment (conus and epiconus)
and roots

Reflexes Knee jerks preserved but ankle Both ankle and knee jerks affected.
jerks affected. bulbocavernosus reflex is absent in low
bulbocavernosus reflex may be
spared
CE (sacral) lesions

Sphincter and Early and severe bowel, Usually late and of lesser
sexual bladder, and sexual magnitudelower sacral roots
dysfunction that results in a
function reflexic bowel and bladder
involvement can cause bladder,
with impaired erection in bowel, and sexual dysfunction
males

EMG Mostly normal lower extremity Multiple

with root level
external anal sphincter involvement; sphincters may also be
involvement
involved
Muscles :
L2 - Hip flexors
(iliopsoas)
L3 - Knee extensors
(quadriceps)
anterior tibialis (L4,
L5, S1),
extensor hallucis
longus (L4, L5, S1),
hamstrings
(L5, S1),
gluteal muscles (L5,
S1), gastrocnemius,
soleus (Ankle plantar
flexors)
(L5, S1, S2)
decreased rectal tone
(S2–S4).