Question
Dear Dr Rahamimov

Thank you so much for such a clear explanation about sequestered
discs.  If it's not too much
trouble, could you also tell me whether or not Cauda Equina Syndrome
(CES) is treatable or is the
damage caused permanent?

Thank you so much for your time and trouble.

Best regards,

Lesley
-------------------------
Followup To
Question -
Shalom Dr Rahamimov,
Could you tell me whether or not, when a sequestered prolapse lumbar
disc (L5/S1) is left
untreated for too long, it could lead to permanent disability and, also,
would surgery still be
worth trying to (hopefully) improve things somehow?

Todah rabbah,


Answer -
/
A sequestrated disc is a fragment of the nucleus pulposus from the
intervertebral disc, residing
within the spinal canal, after extruding through a tear in the annulus
fibrosus surrounding it.
This results in two things: mechanical nerve root compression due to
the volume of the nuclear
fragment, and chemical inflammatory irritation due to the release of
chemical inflammatory
mediators - especially tumor necrosis factor ?found within the disc.
This combination will typically cause a clinical picture of radiculopathy
that in most cases will
resolve by itself even if we do nothing. The sequestrated fragment will
still appear on imaging
studies such as MRI, long after the symptoms have resolved
completely. In other cases, the disc
will actually be absorbed with time and appear smaller or even
disappear.  In rat models it has
been demonstrated that prolonged exposure to nucleus material can
cause permanent damage
to the nerve roots, but the usefulness of this information in a clinical
setting is not clear.
My routine is to treat such patients conservatively if there is no
significant neurological damage. I
do not know any surgeon who will operate an asymptomatic patient
just because there is a
sequestrated disc on MRI. On the other hand, if you are symptomatic
surgery might be an option
regardless of the length of time the disc fragment has sequestrated.


Sincerely,

Dr. N. Rahamimov


Answer
/
Dear Lesely,

Acute cauda equina syndrome is usually treated on an emergent basis.  Opinions differ as to the exact timing, but most agree that surgery should be done within the first 48 hours. Root compression syndromes without neurological deficit can be treated surgically months after the onset of symptoms.

Dr. N. Rahamimov