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Spinal epidural abscess may present as a monoradiculopathy evolving into polyradiculopathy55 60 Suspicion should be heightened in context of fever or other constitutional symptoms, intravenous drug abuse or indwelling catheters, percussion tenderness of the spine, or recent bacteremia Either primary or metastatic tumors with an af nity for the lumbosacral spine, the paravertebral lymph nodes, or meninges should be considered with prominent back pain, which dramatically worsens at night or persists unabated in the supine position Chordomas and myeloma are examples of primary tumors of the vertebral spine, which may produce a cauda equina syndrome through a compression mechanism Prostate, breast, and lung cancer are the more common causes of tumors with an af nity to metastasize to bone Metastatic disease to the lumbosacral spine is estimated to account for <1% of patients with low back pain Back pain as a presenting feature of an occult malignancy is even rarer Vertebral metastases occur in the lumbosacral region in approximately 30% of the time61 Primary tumors with an af nity for cauda equina include schwannomas,62 ependymomas, neuro bromas, meningiomas, lipomas, hemangioblastomas, or dermoid tumors Polyradiculopathy can also occur as a manifestation of occult myelodysplasia It has been reported to occur in association with epidural lipomatosis63 A number of malignancies have a predilection for meninges and are capable of producing a polyradiculopathy via invasion and/or encasement of nerve roots (and/or cranial nerves) Leukemia, non-Hodgkin lymphoma, breast, lung, melanoma, and gastroesophageal malignancies are the most common underlying tumors Usually painful, sequential nerve root lesions affecting arms, trunk, and cranial nerves in addition to lumbosacral roots are the characteristic signature of this disorder A coexisting encephalopathy due to obstructive hydrocephalus or direct cerebral in ltration may coexist64 67 Arachnoiditis is a nonspeci c syndrome in which the arachnoid becomes thickened, scarred, and adherent The cauda equina may be adversely affected due to the direct effects of strangulation or indirectly by obliteration of its blood supply Historically, the syndrome was most closely linked to use of myelographic contrast agents With the development of water-soluble contrast agents, and the declining use of myelographic examinations, the incidence of arachnoiditis not caused by more speci c disease processes discussed in this section is undoubtedly diminished Arachnoiditis may also be caused as an unintended consequence of intended intrathecal injection of therapeutic agents, eg, chemotherapy, or the unintended intrathecal injection of agents that are potentially toxic Diabetes is a common cause of lower extremity pain and weakness It is currently considered to be a radiculoplexus neuropathy, based on pathological and electro-
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diagnostic data It will be discussed in detail as a plexopathy as well as in 19 Dural malformations commonly present with the stepwise progression of lower extremity sensory and motor signs and symptoms, with or without signs and symptoms of genitourinary tract involvement39 42,68 Technically, it should be classi ed as a myeloradiculopathy, as both spinal cord parenchyma and nerve root are vulnerable to the ischemic changes, which is probably the major pathophysiology of this disorder Symptoms may initiate with some traumatic event and may be noted to intensify with either the upright position or the Valsalva maneuver Approximately half of patients who are af icted will have a signi cant painful component Although anatomically a myelopathy in which both lower and upper motor neuron features are clinically apparent, approximately 30% of patients with dural malformations are estimated to have motor features that are predominantly or exclusively lower motor neuron in characteristic As a result, if imaging focuses on the lower lumbar spine and excludes the spinal cord, the unwary physician may overemphasize the signi cance of asymptomatic spondylytic change, leading potentially to unnecessary lumbar laminectomy At times, the sensory signs and symptoms created by dural malformations are minor and may be overlooked In this situation, both the clinical and the electrodiagnostic patterns may suggest motor neuron disease Abnormalities in the H re ex, which may occur in dural malformations, are a potentially helpful means to distinguish these disorders39,40,47,69 Spinal cord infarction from whatever cause, technically a conus rather than cauda disorder, may mimic a lumbosacral polyradiculopathy, particularly from an electrodiagnostic perspective70,71 Radiation may result in a neuropathy affecting the lower extremities72 80 Its onset is typically delayed It most commonly occurs in the context of treatment of testicular cancer or lymphoma Radiation doses typically exceed 4000 cGY The latency between radiation and onset of symptoms averages 6 years The range, however, is exceedingly broad, with onset latency varying between 4 months and 25 years As postirradiation neuropathy is frequently a pure motor syndrome, the actual localization of nerve injury has been in dispute Less than a third of patients have notable sensory symptoms or signs Whether the pathology preferentially occurs in the anterior horn cells of the conus medullaris, the ventral roots, the lumbosacral plexus, or a combination of any of the aforementioned elements is uncertain73 Current evidence, including reports of root enhancement on MR imaging in some patients, favors a polyradiculopathic localization72,73,81,82 Typically the de cits are bilateral and asymmetric, although monomelic presentations do occur76 Any segment may be affected, with L5 and S1 de cits being the most frequent Pain may occur but typically follows the development of weakness
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