Cauda Equina Injury

[spandanphysio]

Hello frinds,.Nice to meet all physios here.I have pt who had dislocated fracture L1 after flexion type of injury 3 months back.M.R.I report showed posteriorly displaced fracture L1 with
cauda equina contusion.He was operated and fixation has been done.right now muscle power is as below,
Right leg is better than left from initiation.Both side hip flexor,adducturs,quad. shows full recovery with 5
Abductor R 2++,L 2+..Hams. R-3,L-2+
Ankle dorsiflexor R-2++,L-1+..Plantar flexors completely paralyzed both side
Hip extensor R-2+,L-1++
ER R-2+,L-2+.IR R-2++,L-2+
pt is having anathesia around paraanal region.Also heaviness and continous 'something is flowing in legs' sensation around both ankles and slight in gluteal region.bladder bowel control is lost but having urine sensation not anal.
Now my question is that after observing fast recovery initially i have not seen any markable recovery since last month,so it's a contusion so should i expect 95-100% recovery?
what will be the recovery pattern in case of such type of injury?
once fliker contraction is achieved(grade-1) how much time is taken to reach normaL power?
what about glutei as they only r coming in wat to achieve indipendant standing?
what can i do to enhance blader bowel control?
pls share u r kind opinion & sugestions.

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[neurospast]

You write that the accident was 3 months ago, you do not write when the operation was done and how succesful it was. What does MRI show? This is important because the accident might have caused a contusion but that doesn't mean this situation is still a fact after the operation. Why was an operation performed was a more conservative treatment not possible? Or was the situation life threatening?
An operation will cause a second injury (unfortunately) and this will effect the area of L1 in general, oedemia, built up of scar tissue and so on. Initially one will always have an improvement with or without treatment since the oedemia caused by both trauma's will decrease after lets say 2 weeks to a month. After that you will have the situation where you could say the improvement is purely due to treatment (to put it black and white). A problem occurs meanwhile since there will be a built up of scar tissue which will influence the space. So there are some issues you might have little influence on.
Your question though will there be a 100% recovery is hard to answer because it is to soon to say. You have to know more about the background, as I tried to ask you. Answer the questions above and you will be able to tell the chance of a 100% recovery. At this point I would say it is more like looking into a glassball and predicting the future.

[spandanphysio]

Thanx neurospast for opinian as i mentioned m.r.i showed posteriorly displaced wedged fracture L1 with contusion of cauda equina.pt had gone for cord decompression within 24 hour of injury with extended incision on left side.right now toe flexor has started to recover with flicer contraction and bowel recovered almost totaly.i want to know that to reach from grade 2 to the grade 3 generally how much time is taken?once he had a fliker contraction in muscle that means that will it recover totaly?what will be recorey pattern generally in cauda equina injury?pls share u r experiences.

[neurospast]

I am sorry to respond this late. I have been trying to point out that there is no time set for recovery neither how much recovery. But the faster essential things are coming back the better the chance of 'full' recovery. I do understand that there has been at the time of your writing, the 2nd March quite some recovery which is great it but still a 'full' recovery will take a lot of time, years? (when I put 'full' I mean that there is no certainty of full recovery even if the diagnose might be contusion this doesn't garranty a full recovery) In general do not give up on your patient but don't give him false hope either. Better think of maximising the recovery.

[spandanphysio]

hi neuropast complete recovery willn't take years as there is no or very slow recovery after 1 year.he has grade 3 in left hams. as well 2+ dorsiflexors in left foot now.hoping that glutei and abductor will recover in next few months.is there any specific recovery pattern for periferal nerves i.e from distal to proximal?i agree that we should go for prognostic signs rather than any factor.

[neurospast]

With recovery it is hard to say what will come back first. This is depending where actually the injury has taken place, which nerves have been severed the most. An MRI after the actual surgery could tell the most because it would show (in principle) which nerves have been affected. You could think also as followed: e.g. S2 supplies dermatomes, muscles and alike. the further away the less likely a full recovery. having said this a problem arises again because one doesn't know when a nerve is affected which part is affected. when a 1 fibre is damaged as much as a 4 fibre the 1 fibre will most likely have a better chance to recover (less complex). The longer a fibre is the less likely it is to recover. I try to point out that it is all very complex and therefor unpredictable.

[spandanphysio]

hello every1 the pt has achieved grade 3 power in his right hams.also some power increase in glue and abductors.he can lift 3kg for glutie in suspension and 2.5 for abductors.so how much time he will take to completely achieve grade-3 power in both sides?and yes one major question is for me is that why blader recorey will come always last?pt. is tired erom catheter.

[spandanphysio]

Hello friends after 1 1/2 year the pt has 3 in right abdutor.2++ in right glutei.still left abductors is 2+ and glutei is 2+.he is able to pass about 60 to 70percant of urine.still chance to achieve good power in both legs to achieve independent standing.he can walk without any support but with excessive lordosis and trunk movts....pls put u r suggestions.in which activities i can achieve poor and isolated gluteaL contraction?