'Diffuse Enhancement of Cauda Equina" finding on MRI?

Tagged: Bursitis, Cauda Equina, Nerve damage

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Cindy121
Participant

August 31, 2016 at 6:17 pm

Post count: 2

#22883

Thank you for your time, doctor. This finding concerned me based upon my own internet research. My PCP is just treating me with steroids and if that helps the pain, the inflammation shouldn’t appear on next image. I am more concerned about knowing what caused this irritation in the first place. What diagnostic process would you follow? I have thought through my symptoms and timeframe and would like to ask if my theory is possible. I started having left leg and hip and thigh pain a year ago after I was taking 3-4 mile walks a few times a week. When it continued and I had clear x rays, lumbar MRI, ultrasound and bone scan through the fall into winter when it became too cold for outdoor walking, In retrospect, I remembered having a very painful trauma to my hip in the middle of the night the previous June when I got a new adjustable bed. I had the head raised and in the “bend” of the bed I was not yet accustomed to my hip falling in that area or to the fact that it is a hybrid with alternating coils, and I remembered that half-asleep injury. My pain increased into the spring and I was unable to take walks at all. I could only walk around in the kitchen 10 minutes without sharp pain in my left side of calf, left side of abdomen, hip/thigh area, lower back. I went to physical therapy for a month and flunked out due to lack of feeling any better. Next I went to a physiatrist who gave me a cortisone shot after evaluating me and diagnosing me with bursitis in my hip. OK, but the pain got worse, sitting on a hard surface, backs of thighs sometimes, not even able to move in the morning at first. (Not pain in all areas mentioned at same time or of same severity), That brought me to last week’s MRI. I also had a finding of a narrowing of the left root exit, Could I have more than one thing going on? Is it possible that the nerves near the damaged bursa also caused enough nerve damage to inflame the cauda equina nerves? Do those nerves calm down, go back to normal or do I have permanent damage that means I have or will have the syndrome? Any thoughts you could provide would be greatly appreciated particularly how to figure out what caused it, how would you recommend I proceed? I appreciate this SO much. (my MRI did not show anything “mechanical” going on like compression, etc. Just mild age-related degeneration) Cindy121

Donald Corenman, MD, DC
Moderator

September 1, 2016 at 6:30 am

Post count: 8660

#22889

I am somewhat confused as you convey in your writing that there has been previous communication. Was there a previous thread that is now disconnected from this one that has more information? I will try to help you based upon this single communication.

You note Hip and thigh pain along with leg pain on the left. Your pain seems to be associated with walking and I will assume that sitting or bending forward will reduce your pain. You have a diagnosis of “bursitis” but your pain is much more diffuse than bursitis will cause. You don’t note the full findings on your MRI but do note there is “a finding of a narrowing of the left root exit” but don’t note the level of this finding.

By sifting through your thread, I come up with the possibility of foraminal stenosis or foraminal collapse. This is a condition where the exit hole from the spine is significantly narrowed. Standing and walking will further narrow this hole and “pinch” the exiting nerve thereby increasing leg pain with standing and walking. See these two sections on this website.

Nerve compression symptoms commonly refer to the hip bursa which can lead to the incorrect diagnosis of a greater trochanteric bursitis.

I hope you also had X-rays which can indicate vertebral unleveling leading to this diagnosis (with a good history and physical examination along with the MRI findings).

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

Cindy121
Participant

September 1, 2016 at 7:48 am

Post count: 2

#22892

I apologize, doctor. I am thrilled to have heard back from you so promptly, then immediately realize the more obvious confusion I caused. My only “previous communication” is the title of my question about the finding of diffuse enhancement of the cauda equina on my MRI. I’m feeling like it’s necessary to know what CAUSED that irritation, not just seeing if steroids will calm it down. I guess I was “grasping” at straws to suggest that, in our complex system of nerves, it could possibly be traced back to a hip trauma. I also thought that my other leg pain was referred from the hip. I looked through many previous Q & As in the forum that mention the cauda equina. (I did see that some people practically sent you the entire MRI report) I cannot copy that from my patient portal and do not have a paper copy yet. Perhaps if I try to restate my main concern? What could be causing the finding of ” diffuse enhancement of the cauda equina of intermediate etiology”? I have read autoimmune disease, infection, polyneuropathy, cancer, etc., which are all scary differential diagnoses to me. Further:: “mild discogenic edema at L5-S1……broad based posterior disc bulge with mild central canal narrowing at L4-L5 and ….left foraminal disc protrusion with moderate left foraminal narrowing, crowding of the exiting of the left L5 nerve roots…no evidence of pathological compression fracture or cord compression…”. I have read your responses to many patients asking about cauda equina, but they weren’t reporting a problem there as already being seen in imaging. It seems unrelated to exit nerve narrowing, which I do understand could be referring pain to my left leg. (Is there a treatment for that?) Does that mean that seeing a diffuse enhancement of the cauda equina is a separate finding entirely and attributable to one of the causes above? Is it reversible? I realize I do not have the syndrome itself or it would be causing much more severe symptoms, but is that where it’s headed. I feel like I need to know the cause. Are there blood tests? Test spinal fluid?
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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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