Cauda equina syndrome

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Cauda equina syndrome
Gray662.png
The cauda equina is the "horse tail" of nerves that branch off after the conus medullaris
Specialty Neurosurgery, orthopedics
Symptoms Low back pain, pain that radiates down the leg, numbness around the anus, loss of bowel or bladder control [1]
Usual onsetRapid or gradual [1]
Causes Disc herniation, spinal stenosis, cancer, trauma, epidural abscess, epidural hematoma [1] [2]
Diagnostic method Medical imaging (MRI, CT scan) [1] [3]
TreatmentSurgery (laminectomy) [1]
Prognosis 20% risk of poor outcome
Frequency1 in 500,000 a year

Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. [2] Signs and symptoms include low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control. [1] Onset may be rapid or gradual. [1]

Contents

The cause is usually a disc herniation in the lower region of the back. [1] Other causes include spinal stenosis, cancer, trauma, epidural abscess, and epidural hematoma. [1] [2] The diagnosis is suspected based on symptoms and confirmed by medical imaging such as MRI or CT scan. [1] [3]

CES is generally treated surgically via laminectomy. [1] Sudden onset is regarded as a medical emergency requiring prompt surgical decompression, with delay causing permanent loss of function. [4] Permanent bladder problems, sexual dysfunction or numbness may occur despite surgery. [1] [3] A poor outcome occurs in about 20% of people despite treatment. [1] About 1 in 70,000 people is affected every year. [1] It was first described in 1934. [5]

Signs and symptoms

Approximate area of "saddle anesthesia" seen from behind (yellow highlight) Saddle anesthesia.png
Approximate area of "saddle anesthesia" seen from behind (yellow highlight)

Signs and symptoms of cauda equina syndrome include:

Severe back pain, saddle anesthesia, urinary or fecal incontinence and sexual dysfunction are considered "red flags", i.e. features which require urgent investigation. [8]

Causes

After the conus medullaris (near lumbar vertebral levels 1 (L1) and 2 (L2), occasionally lower), the spinal canal contains a bundle of nerve fibers (the cauda equina or "horse-tail") that branches off the lower end of the spinal cord and contains the nerve roots from L1–L5 and S1–S5. The nerve roots from L4–S4 join in the sacral plexus which affects the sciatic nerve, which travels caudally (toward the feet). Compression, trauma or other damage to this region of the spinal canal can result in cauda equina syndrome.[ citation needed ]

The symptoms may also appear as a temporary side-effect of a sacral extra-dural injection. [9]

Trauma

Direct trauma can also cause cauda equina syndrome. Most common causes include as a complication of lumbar punctures, burst fractures resulting in posterior migration of fragments of the vertebral body, severe disc herniations, spinal anaesthesia involving trauma from catheters and high local anaesthetic concentrations around the cauda equina, penetrating trauma such as knife wounds or ballistic trauma. [10] Cauda equina syndrome may also be caused by blunt trauma suffered in an event such as a car accident or fall. [11]

Spinal stenosis

CES can be caused by lumbar spinal stenosis, which is when the diameter of the spinal canal narrows. This could be the result of a degenerative process of the spine (such as osteoarthritis) or a developmental defect which is present at birth. In the most severe cases of spondylolisthesis cauda equina syndrome can result. [10]

Inflammatory conditions

Chronic spinal inflammatory conditions such as Paget disease, neurosarcoidosis, chronic inflammatory demyelinating polyneuropathy, ankylosing spondylitis, rheumatoid disease of the spine, and chronic tuberculosis can cause it. This is due to the spinal canal narrowing that these kinds of syndromes can produce. [10]

Risk factors

Individuals most at risk for disc herniation are the most likely to develop CES. Race has little influence with the notable exception that African Americans appear slightly less likely to develop CES than other groups. [12] [13] [14] Middle age also appears to be a notable risk factor, as those populations are more likely to develop a herniated disc; heavy lifting can also be inferred as a risk factor for CES. [12] [14]

Other risk factors include obesity and being female. [15]

Diagnosis

MRI of an abscess causing cauda equina syndrome MRI of the lumbar spine with abscess in the posterior epidural space, causing cauda equina syndrome.jpg
MRI of an abscess causing cauda equina syndrome

Diagnosis is first suspected clinically based on history and physical exam and usually confirmed by an MRI scan or CT scan, depending on availability. [4] Bladder scanning and loss of catheter sensation can also be used to evaluate bladder dysfunction in suspected cases of cauda equina syndrome and can aid diagnosis before MRI scanning.[ citation needed ] Early surgery in acute onset of severe cases has been reported to be important. [4]

Prevention

Early diagnosis of cauda equina syndrome can allow for preventive treatment. Signs that allow early diagnosis include changes in bowel and bladder function and loss of feeling in groin. [16] Changes in sensation can start as pins and needles leading to numbness. Changes in bladder function may be changes to stream or inability to fully empty the bladder. If a person progresses to full retention intervention is less likely to be successful.[ citation needed ]

Management

The management of true cauda equina syndrome frequently involves surgical decompression. When cauda equina syndrome is caused by a herniated disk early surgical decompression is recommended. [17]

Sudden onset cauda equina syndrome is regarded as a medical/surgical emergency. [4] Surgical decompression by means of laminectomy or other approaches may be undertaken within 6, [18] 24 [19] or 48 hours of symptoms developing if a compressive lesion (e.g., ruptured disc, epidural abscess, tumor or hematoma) is demonstrated. Early treatment may significantly improve the chance of avoiding long-term neurological damage. [17] [19]

Surgery may be required to remove blood, bone fragments, a tumor or tumors, a herniated disc or an abnormal bone growth. If the tumor cannot be removed surgically and is malignant then radiotherapy may be used as an alternative to relieve pressure. Chemotherapy can also be used for spinal neoplasms. If the syndrome is due to an inflammatory condition e.g., ankylosing spondylitis, anti-inflammatory, including steroids can be used as an effective treatment. If a bacterial infection is the cause then an appropriate course of antibiotics can be used to treat it. [20]

Cauda equina syndrome can occur during pregnancy due to lumbar disc herniation. The risk of cauda equina syndrome during pregnancy increases with age of the mother. Surgery can still be performed and pregnancy does not adversely affect treatment. Treatment for those with cauda equina can and should be carried out at any time during pregnancy. [21]

Lifestyle issues may need to be addressed post-treatment. Issues could include the person's need for physiotherapy and occupational therapy due to lower limb dysfunction. Obesity might also need to be tackled. [20]

Bowel and bladder control

Rehabilitation of CES depends on the severity of the injury. If permanent damage occurs, then impairment in bladder and bowel control may result. [22] Once surgery is performed, resting is required until the bladder and bowel dysfunction can be assessed. Urinary catheterization may help with bladder control. Gravity and exercise can help control bowel movement (Hodges, 2004). Pelvic floor exercises assist in controlling bowel movements (Pelvic Floor Exercises, 2010).[ full citation needed ] These exercises can be done standing, lying, or on all fours with the knees slightly separated. Full recovery of bowel and bladder control can take as long as two years.[ citation needed ]

Prognosis

The prognosis for complete recovery is dependent upon many factors. The most important of these is the severity and duration of compression upon the damaged nerve(s). Generally, the longer the time before intervention to remove the compression causing nerve damage, the greater the damage caused to the nerve(s).[ citation needed ]

Damage can be so severe that nerve regrowth is impossible, and the nerve damage will be permanent. In cases where the nerve has been damaged but is still capable of regrowth, recovery time is widely variable. Surgical intervention with decompression of the cauda equina can assist recovery. Delayed or severe nerve damage can mean up to several years' recovery time because nerve growth is exceptionally slow.[ citation needed ]

Review of the literature indicates that around 50–70% of patients have urinary retention (CES-R) on presentation with 30–50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression. CES-I with its more favourable prognosis may become CES-R at a later stage. [23]

Epidemiology

The nerve roots extending from the lumbar spine are susceptible to compression, leading to CES. Intervertebral discs can be dislocated to different degrees, contributing to such compression. Spinal cord diagram KIN 412.png
The nerve roots extending from the lumbar spine are susceptible to compression, leading to CES. Intervertebral discs can be dislocated to different degrees, contributing to such compression.

Various etiologies of CES include fractures, abscesses, hematomas, and any compression of the relevant nerve roots. [24] Injuries to the thoracolumbar spine will not necessarily result in a clinical diagnosis of CES, but in all such cases it is necessary to consider. Few epidemiological studies of CES have been done in the United States, owing to difficulties such as amassing sufficient cases as well as defining the affected population, therefore this is an area deserving of additional scrutiny. [12]

Traumatic spinal cord injuries occur in approximately 40 people per million annually in the United States, resulting from traumas due to motor vehicle accidents, sporting injuries, falls, and other factors. [13] An estimated 10 to 25% of vertebral fractures will result in injury to the spinal cord. [13] Thorough physical examinations are required, as 5 to 15% of trauma patients have fractures that initially go undiagnosed. [25]

The most frequent injuries of the thoracolumbar region are to the conus medullaris and the cauda equina, particularly between T12 and L2. [13] Of these two syndromes, CES is the more common. [13] CES mainly affects middle-aged individuals, particularly those in their forties and fifties, and presents more often in men. [13] [14] [26] It is not a typical diagnosis, developing in only 4 to 7 out of every 10,000 to 100,000 patients, and is more likely to occur proximally. [12] [13] [14] Disc herniation is reportedly the most common cause of CES, and it is thought that 1 to 2% of all surgical disc herniation cases result in CES. [12] [13]

CES affects mainly middle-aged individuals. There is a significant cost associated with hospital admissions, as CES is considered an emergent condition. Stats graphs KIN 412.png
CES affects mainly middle-aged individuals. There is a significant cost associated with hospital admissions, as CES is considered an emergent condition.

CES is often concurrent with congenital or degenerative diseases and represents a high cost of care to those admitted to the hospital for surgery. [13] [26] Hospital stays generally last 4 to 5 days, and cost an average of $100,000 to $150,000. [26] Delays in care for cauda equina results in the English NHS paying about £23 million a year in compensation. [27]

In animals

Degenerative lumbosacral stenosis (DLSS), also known as cauda equina syndrome, is a pathologic degeneration in the lumbosacral disk in dogs. DLSS affects the articulation, nerve progression, and tissue and joint connections of the disk. [28] [29] This degeneration causes compressions in soft tissues and nerve root locations in the caudal area of the medulla, causing neuropathic pain in the lumbar vertebrae. [30] [31]

Related Research Articles

<span class="mw-page-title-main">Back pain</span> Area of body discomfort

Back pain is pain felt in the back. It may be classified as neck pain (cervical), middle back pain (thoracic), lower back pain (lumbar) or coccydynia based on the segment affected. The lumbar area is the most common area affected. An episode of back pain may be acute, subacute or chronic depending on the duration. The pain may be characterized as a dull ache, shooting or piercing pain or a burning sensation. Discomfort can radiate to the arms and hands as well as the legs or feet, and may include numbness or weakness in the legs and arms.

<span class="mw-page-title-main">Tetraplegia</span> Paralysis of all four limbs and torso

Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis. The paralysis may be flaccid or spastic. A loss of sensory function can present as an impairment or complete inability to sense light touch, pressure, heat, pinprick/pain, and proprioception. In these types of spinal cord injury, it is common to have a loss of both sensation and motor control.

<span class="mw-page-title-main">Cauda equina</span> Anatomical structure

The cauda equina is a bundle of spinal nerves and spinal nerve rootlets, consisting of the second through fifth lumbar nerve pairs, the first through fifth sacral nerve pairs, and the coccygeal nerve, all of which arise from the lumbar enlargement and the conus medullaris of the spinal cord. The cauda equina occupies the lumbar cistern, a subarachnoid space inferior to the conus medullaris. The nerves that compose the cauda equina innervate the pelvic organs and lower limbs to include motor innervation of the hips, knees, ankles, feet, internal anal sphincter and external anal sphincter. In addition, the cauda equina extends to sensory innervation of the perineum and, partially, parasympathetic innervation of the bladder.

<span class="mw-page-title-main">Sciatica</span> Lower back pain that extends down leg

Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities like heavy lifting, though gradual onset may also occur. The pain is often described as shooting. Typically, symptoms are only on one side of the body. Certain causes, however, may result in pain on both sides. Lower back pain is sometimes present. Weakness or numbness may occur in various parts of the affected leg and foot.

<span class="mw-page-title-main">Discectomy</span> Surgical removal of an intervertebral disc

A discectomy is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an intervertebral disc, which causes pain, weakness or numbness by stressing the spinal cord or radiating nerves. The traditional open discectomy, or Love's technique, was published by Ross and Love in 1971. Advances have produced visualization improvements to traditional discectomy procedures, or endoscopic discectomy. In conjunction with the traditional discectomy or microdiscectomy, a laminotomy is often involved to permit access to the intervertebral disc. Laminotomy means a significant amount of typically normal bone is removed from the vertebra, allowing the surgeon to better see and access the area of disc herniation.

<span class="mw-page-title-main">Lumbar spinal stenosis</span> Narrowing of the lower spinal canal

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. Lumbar spinal stenosis can cause pain in the low back or buttocks, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control.

<span class="mw-page-title-main">Spondylosis</span> Degeneration of the vertebral column

Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints. If severe, it may cause pressure on the spinal cord or nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

<span class="mw-page-title-main">Degenerative disc disease</span> Medical condition

Degenerative disc disease (DDD) is a medical condition typically brought on by the aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with or without symptoms, but is typically identified once symptoms arise. The root cause is thought to be loss of soluble proteins within the fluid contained in the disc with resultant reduction of the oncotic pressure, which in turn causes loss of fluid volume. Normal downward forces cause the affected disc to lose height, and the distance between vertebrae is reduced. The anulus fibrosus, the tough outer layers of a disc, also weakens. This loss of height causes laxity of the longitudinal ligaments, which may allow anterior, posterior, or lateral shifting of the vertebral bodies, causing facet joint malalignment and arthritis; scoliosis; cervical hyperlordosis; thoracic hyperkyphosis; lumbar hyperlordosis; narrowing of the space available for the spinal tract within the vertebra ; or narrowing of the space through which a spinal nerve exits with resultant inflammation and impingement of a spinal nerve, causing a radiculopathy.

<span class="mw-page-title-main">Spinal fusion</span> Immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies

Spinal fusion, also called spondylodesis or spondylosyndesis, is a surgery performed by orthopaedic surgeons or neurosurgeons that joins two or more vertebrae. This procedure can be performed at any level in the spine and prevents any movement between the fused vertebrae. There are many types of spinal fusion and each technique involves using bone grafting—either from the patient (autograft), donor (allograft), or artificial bone substitutes—to help the bones heal together. Additional hardware is often used to hold the bones in place while the graft fuses the two vertebrae together. The placement of hardware can be guided by fluoroscopy, navigation systems, or robotics.

Congenital vertebral anomalies are a collection of malformations of the spine. Most, around 85%, are not clinically significant, but they can cause compression of the spinal cord by deforming the vertebral canal or causing instability. This condition occurs in the womb. Congenital vertebral anomalies include alterations of the shape and number of vertebrae.

Failed back syndrome or post-laminectomy syndrome is a condition characterized by chronic pain following back surgeries. Many factors can contribute to the onset or development of FBS, including residual or recurrent spinal disc herniation, persistent post-operative pressure on a spinal nerve, altered joint mobility, joint hypermobility with instability, scar tissue (fibrosis), depression, anxiety, sleeplessness, spinal muscular deconditioning and even Cutibacterium acnes infection. An individual may be predisposed to the development of FBS due to systemic disorders such as diabetes, autoimmune disease and peripheral blood vessels (vascular) disease.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

<span class="mw-page-title-main">Cervical spinal stenosis</span> Narrowing of the upper spinal canal

Cervical spinal stenosis is a bone disease involving the narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration, but may also be congenital. Treatment is frequently surgical.

<span class="mw-page-title-main">Neurogenic claudication</span> Discomfort in the legs during walking due to nerve impingement

Neurogenic claudication (NC), also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis (LSS) and describes intermittent leg pain from impingement of the nerves emanating from the spinal cord. Neurogenic means that the problem originates within the nervous system. Claudication, from Latin claudicare 'to limp', refers to painful cramping or weakness in the legs. NC should therefore be distinguished from vascular claudication, which stems from a circulatory problem rather than a neural one.

<span class="mw-page-title-main">Laminotomy</span> Surgical procedure

A laminotomy is an orthopaedic neurosurgical procedure that removes part of the lamina of a vertebral arch in order to relieve pressure in the vertebral canal. A laminotomy is less invasive than conventional vertebral column surgery techniques, such as laminectomy because it leaves more ligaments and muscles attached to the spinous process intact and it requires removing less bone from the vertebra. As a result, laminotomies typically have a faster recovery time and result in fewer postoperative complications. Nevertheless, possible risks can occur during or after the procedure like infection, hematomas, and dural tears. Laminotomies are commonly performed as treatment for lumbar spinal stenosis and herniated disks. MRI and CT scans are often used pre- and post surgery to determine if the procedure was successful.

<span class="mw-page-title-main">Spinal disease</span>

Spinal disease refers to a condition impairing the backbone. These include various diseases of the back or spine ("dorso-"), such as kyphosis. Dorsalgia refers to back pain. Some other spinal diseases include spinal muscular atrophy, ankylosing spondylitis, scoliosis, lumbar spinal stenosis, spina bifida, spinal tumors, osteoporosis and cauda equina syndrome.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

The TESSYS method is a minimally-invasive, endoscopic spinal procedure for the treatment of a herniated disc. It was a further development of the YESS method by the Dutch Dr Thomas Hoogland in the Alpha Klinik in Munich in 1989 and was first called THESSYS. The procedure involves performing a small foramenotomy and removal of soft tissue compressing the nerve root.

Degenerative lumbosacral stenosis (DLSS), also known as cauda equina syndrome, is a pathologic degeneration in the lumbosacral disk in dogs; affecting the articulation, nerve progression, tissue and joint connections of the disk. This degeneration causes compressions in soft tissues and nerve root locations in the ultimate caudal area of the medulla, causing neuropathic pain in the lumbar vertebrae.

References

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  5. ↑ Chau AM, Xu LL, Pelzer NR, Gragnaniello C (2014). "Timing of surgical intervention in cauda equina syndrome: a systematic critical review". World Neurosurgery. 81 (3–4): 640–50. doi:10.1016/j.wneu.2013.11.007. PMID   24240024.
  6. ↑ Larner AJ (2006). A Dictionary of Neurological Signs (2nd ed.). [New York]: Springer Science+Business Media, Inc. ISBN   9780387262147.
  7. 1 2 Kraemer (2009). Intervertebral disk diseases causes, diagnosis, treatment, and prophylaxis (3rd ed.). Stuttgart: Thieme. ISBN   9783131495617.
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  15. ↑ Long B, Koyfman A, Gottlieb M (January 2020). "Evaluation and management of cauda equina syndrome in the emergency department". The American Journal of Emergency Medicine. 38 (1): 143–148. doi: 10.1016/j.ajem.2019.158402 . PMID   31471075.
  16. ↑ Eck JC (11 May 2007). "Prevention". Cauda Equina Syndrome. WebMD . Retrieved 25 April 2009.
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  18. ↑ "Neurosurgery for Cauda Equina Syndrome". Medscape. November 11, 2013. Retrieved 18 March 2015.
  19. 1 2 "Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life". Canadian Association of Emergency Physicians. July 10, 2001. Archived from the original on 21 March 2015. Retrieved 18 March 2015.
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  23. ↑ Gardner A, Gardner E, Morley T (May 2011). "Cauda equina syndrome: a review of the current clinical and medico-legal position". European Spine Journal. 20 (5): 690–7. doi:10.1007/s00586-010-1668-3. PMC   3082683 . PMID   21193933.
  24. ↑ Gitelman A, Hishmeh S, Morelli BN, Joseph SA, Casden A, Kuflik P, et al. (November 2008). "Cauda equina syndrome: a comprehensive review". American Journal of Orthopedics. 37 (11): 556–62. PMID   19104682.
  25. ↑ Harrop JS, Hunt GE, Vaccaro AR (June 2004). "Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles". Neurosurgical Focus. 16 (6): e4. doi: 10.3171/foc.2004.16.6.4 . PMID   15202874.
  26. 1 2 3 "National and regional estimates on hospital use for all patients from the HCUP nationwide inpatient sample (NIS)". United States Department of Health and Human Services Agency for Healthcare Research. 2012. Archived from the original on 2015-03-01. Retrieved 2013-05-23.
  27. ↑ "Delayed spinal surgery costs £23m in compensation". Health Service Journal. 30 January 2019. Retrieved 5 March 2019.
  28. ↑ Danielsson F, Sjöström L (1999). "Surgical treatment of degenerative lumbosacral stenosis in dogs". Veterinary Surgery. 28 (2): 91–8. doi: 10.1053/jvet.1999.0091 . PMID   10100762.
  29. ↑ Jeffery ND, Barker A, Harcourt-Brown T (July 2014). "What progress has been made in the understanding and treatment of degenerative lumbosacral stenosis in dogs during the past 30 years?". Veterinary Journal. 201 (1): 9–14. doi:10.1016/j.tvjl.2014.04.018. PMID   24878265.
  30. ↑ Giudice E, Crinò C, Barillaro G, Crupi R, Macrì F, Viganò F, Di Pietro S (2019-09-01). "Clinical findings in degenerative lumbosacral stenosis in ten dogs—A pilot study on the analgesic activity of tramadol and gabapentin". Journal of Veterinary Behavior. 33: 7–15. doi:10.1016/j.jveb.2019.05.004. ISSN   1558-7878. S2CID   181851509.
  31. ↑ Meij BP, Bergknut N (September 2010). "Degenerative lumbosacral stenosis in dogs". The Veterinary Clinics of North America. Small Animal Practice. 40 (5): 983–1009. doi:10.1016/j.cvsm.2010.05.006. PMID   20732601.
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