The cauda equina demonstrate clumping of the nerve roots seen commencing at the L2/L3 level and extending down to the sacral cul de sac. Treatment options for arachnoiditis are similar to those for other chronic pain conditions. It occupies the lumbar cistern, which is an enlargement of the subarachnoid space containing cerebrospinal fluid (CSF).. Also extending distally from the apex of the conus medullaris is the filum terminale, a vestigial . L2/3: Asymmetric disc bulge extending beyond the left lateral aspect of the vertebral body. Arachnoiditis is now rarely seen with the use of water-soluble, nonionic contrast agents. Create a daily schedule that includes a few priorities and time for rest and self-care. To enhance pain relief and minimize opioids, the use of ketamine, adrenergic agents, and topical anesthetics have been helpful. A sleep aid may be necessary to not only induce sleep but to assist CNS lymphatic drainage.. The average areas (mm (2)) of anterior right and left nerves were 1.40 and 1.23, respectively, for patients and 0.61 and 0.60 for controls (differences: 0.79 and 0.63; p < 0.001). Compression may also occur due to tumors, cysts, stenosis (abnormal narrowing of the spinal canal), or trauma. Shaw MD, Russel JA, Grossart KW. 5. %PDF-1.5 % Having depression or anxiety can make your chronic pain worse. The course of this condition remains highly variable since arachnoiditis can be either a static (stays the same) or progressive (gets worse over time) disease. The anatomy of the cauda equina on CT scans and MRI. Here's what you may need to confirm a diagnosis: If you have cauda equina syndrome, you'll need prompt treatment to relieve pressure on nerves. There are several medications prescribed to address pain, bladder and bowel problems. Some severe patients literally have so much pain, fatigue, and disability that they report to me that they spend 80% to 90% of their time in bed. Spinal arachnoiditis: disease or coincidence? Cleveland Clinic is a non-profit academic medical center. Mayil S. Krishnam, John Curtis. Pract Pain Manag. Many of these patients also require long term follow-up with rehabilitation medicine. Patients may not be able to do straight leg raises or flex one or both feet. CES occurs more often in adults than in children. At the time the article was created The Radswiki had no recorded disclosures. When cauda equina compression occurs, it is a neurosurgical emergency because the nerve roots must be released to prevent lower extremity paraparesis, paralysis, bladder and bowel impairment, and severe pain. Since arachnoiditis can affect both your physical and mental health, its essential to seek proper treatment and advocate for yourself. Tests that May be Helpful in Diagnosing CES. A novel role of minocycline attenuating morphine antinociceptive tolerance by inhibition of p38 MAPK in the activated spinal microglia. The site navigation utilizes arrow, enter, escape, and space bar key commands. Symptoms Although early treatment is required to prevent permanent problems, cauda equina syndrome may be difficult to diagnose. Severe or progressive problems in the lower extremities, including loss of or altered sensation between the legs, over the buttocks, the inner thighs and back of the legs (saddle area), and feet/heels. iT@RT0#^ Due to the well-known side effects of indomethacin, ketorolac, and corticosteroid drugs, we do not recommend daily but intermittent administration in an effort to avoid side effects while keeping nerve roots from forming additional adhesions and scars which may cause neurologic impairments. These are the most common causes of cauda equina syndrome: It may be hard to diagnose cauda equina syndrome. Antioxidant properties of minocycline: neuroprotection in an oxidative stress assay and direct radical-scavenging activity. This type of pain tends to produce a burning feeling that can become constant and unbearable. Churchill Livingstone. Patients with CES may develop frequent urinary infections. I highly recommend Dr. Corenman and the Steadman Clinic. Severe shooting pain that can be similar to an electric shock sensation. But in rare cases, severe back pain can be a sign of cauda equina syndrome (CES), a condition that usually requires urgent surgical treatment. Sensory loss may range from pins and needles to complete numbness, and may affect the bladder, bowel and genital areas. Figure 5, shows typical examples of clumped nerve roots within the spinal canal as well as adherence to the arachnoid lining. Over the past 5 years, my clinic has admitted to treatment an increasing number of patients with AA. Topiramate in chronic lumbar radicular pain. J Neurol Neurosurg Psychiatry. Arachnoiditis has several possible causes, and treatment is aimed at managing symptoms. AJR Am J Roentgenol. Epidural injections of indomethacin for postlaminectomy syndrome: a preliminary report. If you have cauda equina syndrome, you may need urgent surgery to remove the material that is pressing on the nerves. Benner B, Ehni G. Spinal arachnoiditis: the post-operative variety in particular. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Oral ketamine for chronic pain: a 32-subject placebo-controlled trial in patients on chronic opioids. Benoliel R, Tal M, Eliav E. Effects of topiramate on the chronic constriction injury model in the rat. Little has been written about the clinical diagnosis and treatment of arachnoiditis. Much of what is written here is the authors personal observations, beliefs, and methods as there are few supporting references in the literature. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, Important Updates + Notice of Vendor Data Event, (https://rarediseases.info.nih.gov/diseases/5839/arachnoiditis), (https://www.ninds.nih.gov/health-information/disorders/arachnoiditis), (https://www.ncbi.nlm.nih.gov/books/NBK555973/). What is adhesive arachnoiditis? This website also contains material copyrighted by third parties. Rydevik B, Holm S, Brown MD, Lundborg G. Diffusion from the cerebrospinal fluid as a nutritional pathway for spinal nerve roots. Inflamed nerve roots on an axial view appear as enlarged (edema), displaced from their normal position, and glued or clumped together (Figure 4). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Diana Wiseman, MD, MBA, FAANS Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage. Tennant F. Erythrocyte sedimentation rate and C-reactive protein: old but useful biomarkers for pain treatment. 1961;2(5243):24-7. 2. Space-occupying lesions, including disc herniation, trauma and tumor, within the spinal canal may compromise the nerve roots, causing severe clinical syndromes. Unfortunately, the nerve roots in the cauda equina are anatomical strings that are freely suspended in fluid. Besides a herniated disc, other conditions with symptoms that can be similar to CES include peripheral nerve disorder, conus medullaris syndrome, spinal cord compression and irritation or compression of the nerves after they exit the spinal column and travel through the pelvis a condition known as lumbosacral plexopathy. Inflammation begins in cauda equina nerve roots leads to Adhesions causing clumping of nerve roots CONCLUSIONS: 1. They can help determine the best treatment plan for you to manage your symptoms. The best MRI image to confirm a diagnosis of AA is usually the axial view of a contrast MRI (Figure 2) at the L3,L4,L5 and S1 levels of the lumbar spine. Pathologic changes in nerve roots can best be visualized by size and placement in the axial view of a contrast MRI. Figure 3 includes diagrams of the cauda equina nerve roots in their normal size and location. Haughton VM, Eldveik OP, Ho KC, Larson SJ, Unger GF. Vale ML, Benevides VM, Sachs D, et al. Symptoms vary in intensity and may evolve slowly over time. Degenerated arthritic joints, trauma, or scoliosis that cause friction or compression between some of the nerve roots also may cause AA. Once inflammation involves some of the nerve roots, it clinically appears to be capable of spread as AA patients recurrently claim that they may worsen following additional trauma, medical procedures (including physical manipulation and paraspinal injections), and even infections. Diagnosis of lumbar arachnoiditis by magnetic resonance imaging. In many cases of arachnoiditis, healthcare providers arent able to determine the exact cause. The goal of pain relief, particularly opioids, is to provide enough pain relief for the patient to exercise and walk daily, carry out activities of daily living, and escape a bed-couch bound state. Nerve roots of the cauda equina are constantly bathed and submerged in spinal fluid that acts as a lubricant against friction between nerves, transports waste products, and brings nutrients to the nerve roots. The spinal fluid turns over about 4 times a day. Therefore, waste products, including inflammatory particles from inflamed nerve roots, are carried upward to drain through channels in the meninges into cervical lymph nodes and general circulation.. This is usually because the nerve roots are in the inflammation and clumping stage but have not yet adhered themselves to the arachnoid lining. Adhesive arachnoiditis can potentially lead to disability. Cauda equina syndrome refers to a collection of symptoms and signs that result from severe compression of the descending lumbar and sacral nerve roots. You may want to use glycerin suppositories or enemas to help empty the bowels. Redundant nerve roots of the cauda equina are characterized by the presence of elongated tortuous nerve roots with serpiginous or coiled appearance near areas of spinal canal stenosis.. Cauda equina syndrome (CES) occurs when there is dysfunction of multiple lumbar and sacral nerve roots of the cauda equina. nxV\y(EHi Spine_. An extension of the brain, the nerve roots send and receive messages to and from the pelvic organs and lower limbs. On the first postoperative day, the drain was removed and fraxiparine was started. Is this possible or is there another form of treatment you can provide to arrest this beast? In my experience, the inability to stand very long is so dominant in these patients that they may even ask to lie on your exam table or on the floor of your office. Clinical Assistant Professor, University of Washington, background-image - a woman looking at a screen, Neurosurgery Research & Education Foundation, Violent injuries to the lower back (gunshots, falls, auto accidents), Spinal arteriovenous malformations (AVMs), Spinal hemorrhages (subarachnoid, subdural, epidural), Postoperative lumbar spine surgery complications. Case 13: massive L4/L5 disc extrusion with cauda equina compression, see full revision history and disclosures. Medical protocols for acute and chronic AA have been developed and are published here for utilization in ambulatory care settings. 1823 0 obj <>stream Patients develop a high prevalence of arthralgia, myalgia, and such autoimmune phenomenon as Hashimotos thyroiditis and carpal tunnel syndrome. Although the mechanism for the development of autoimmune symptoms is unknown, a possible explanation is the drainage of cells and soluble antigens in the spinal fluid into regional lymph nodes. A major treatment goal is to stop the progression, disability, and deterioration that is characteristic of AA patients. MR imaging of lumbar arachnoiditis. Arachnoiditis is unusual to occur absent some injury or insult. Cauda equina syndrome (CES) occurs when there is dysfunction of multiple lumbar and sacral nerve roots of the cauda equina. PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. Tennant F. Which chronic back pain patients have arachnoiditis? 1783 0 obj <> endobj Cauda equina syndrome occurs when the nerve roots in the lumbar spine are compressed, cutting off sensation and movement. Nerve damage and possibly tethered nerves. Pain practitioners need to be aware of this possibility and be prepared to provide emergency treatment to prevent severe disability and impairment. In this MRI scan, a herniated disk (arrow) is compressing the cauda equina. Cauda equina syndrome is a rare disorder that usually is a surgical emergency. bowel, bladder and/or sexual dysfunction. Walking outside the house each day is mandatory. Sensations that may feel like insects crawling on your skin (formication) or water trickling down your leg. On repeat myelography or MRI, the nerve roots of the cauda equina appear thickened, clumped, and adherent to the periphery of the thecal sac. Defining neuroinflammation.. Multiplicity of cerebrospinal fluid functions: new challenges in health and disease. I have reviewed the MRIs from over 200 confirmed patients. It is most commonly caused by an acutely extruded lumbar disc and is considered a diagnostic and surgical emergency. Depending on your limitations, you can seek help from: And, as with many conditions, there may be nothing quite as helpful as support from those who really understand what you're going through. Cauda Equina Syndrome: A Comprehensive Review. Physical examination revealed labored gait, hypoactive leg reflexes, and inability to perform straight leg raise. Nerves are continuous from the origin at the spinal cord to their termination at the end organ (muscle, skin, joint, blew/bladder). The spinal cord ends at the upper portion of the lumbar (lower back) spine. She is able to hold a full-time job and care for her children. It most commonly affects the nerves of your lumbar (low back) and thoracic spine (middle back). Cauda equina consists of spinal nerves L2-L5, S1-S5 and the coccygeal nerve. The conus medullaris forms the last portion of the spinal cord from where the axons of the distal nerve roots originate and where the spinal bowel and bladder centers are located. Even with immediate treatment, some patients may not recover complete function; earlier treatment does, however, offer thebest outcomes for cauda equina syndrome. Once the diagnosis of CES is made and the etiology established, urgent/emergent surgery is usually the treatment of choice. Wang R, King T, De Felcie M, Guo W, Ossipov MH, Porreca F. Descending facilitation maintains long-term spontaneous neuropathic pain. In this patient insufficient information was provided to ascribe these findings to a specific cause. Become a Gold Supporter and see no third-party ads. To illustrate, a case report is given here with the patients chronic management program included. The use of pentoxifylline was initiated by French physicians, and I have also found this treatment to be remarkably effective in select cases. (https://www.practicalpainmanagement.com/pain/spine/arachnoiditis-part-1-clinical-description). 2011;20(5):690-7. We do not endorse non-Cleveland Clinic products or services. ADVERTISEMENT: Supporters see fewer/no ads. You may need blood tests. Although the term arachnoiditis simply implies inflammation of the arachnoid lining of the meninges or thecal sac, the major pathologic abnormality in the majority of cases is neuroinflammation of the nerve roots in the cauda equina. Once glia cells in nerve roots produce neuroinflammation, they may form adhesions and scars that may cause nerve roots to stick together or clump and adhere to the arachnoid lining.. Xle I, Kang H, Xu Q, et al. Conus and cauda equina tumors represent a unique group of tumors due to their specific location in the spinal canal. All modalities will demonstrate similar findings although MRI is by far the most sensitive modality. This may relate to any interval spinal intervention, infection or trauma . 2. They may have already progressed to the point that a walker or wheelchair was necessary to ambulate. A single excessive strain or injury may cause a herniated disc, however, many disc herniations do not necessarily have an identified cause. For example, only 2 traditional anti-inflammatory agents have shown effect in our hands: ketorolac and indomethacin. Ketorolac cannot be used for over 5 consecutive days or on a daily basis with pentoxifylline. The arachnoid mater is the middle layer. The main differential is leptomeningeal carcinomatosisthat can also lead to nerve root clumping although this is not strictly speaking inflammatory in nature and thus not true arachnoiditis. 2005 - 2023 WebMD LLC, an Internet Brands company. Gardner A, Gardner E, Morley T. Cauda Equina Syndrome: A Review of the Current Clinical and Medico-Legal Position. Jeffrey Fudin, PharmD, FCCP, FASHP, FFSMB. Use protective pads and pants to prevent leaks. Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda Equina Syndrome. MyAANS, password-protected resources, and purchases are currently experiencing issues and are unavailable. Enhancement of the roots may occur following intravenous contrast administration. Nerve root irritation or inflammation diagnosed by magnetic resonance imaging. Dont try to do too much. All material on this website is protected by copyright. Patients with complete cauda equina syndrome have a poorer outcome 3. An MRI showed arachnoiditis and she was referred to my clinic. 2016;16(5). Arachnoiditis is also generally not associated with lower back pain. Kunam VK, Velayudhan V, Chaudhry ZA et-al. 2013;82(2):100-8. Minocycline prevents glutamate-induced apoptosis of cerebellar granule neurons by differential regulation of p38 and Akt pathways. If you have symptoms of arachnoiditis, your healthcare provider may order the following tests to help diagnose it: Unfortunately, theres no cure for arachnoiditis. Even patients who undergo surgery after the 48-hour ideal time frame may experience improvement. The weakness can affect lower extremities. Arachnoiditis affecting the cauda equina may be referred to as spinal/lumbar adhesive arachnoiditis. Studies in rats have shown that the corticosteroid, methylprednisolone, and the anti-inflammatory agent indomethacin suppress cauda equina inflammation and adhesion formation. Microglial activation and neuroinflammation formation has, in rats, been shown to be suppressed by: acetazolamide; minocycline; and pentoxifylline. Acetazolamide may also lower spinal fluid pressure as an added benefit. J Craniovertebr Junction Spine. Medical procedures required to treat spinal pathologic abnormalities may accelerate or possibly initiate a neuroinflammatory process in cauda equina nerve roots. endstream endobj startxref In patients with cauda equina syndrome, something compresses on the spinal nerve roots. That's why joining a cauda equina support group may be a good idea. In my experience, 30% to 40% of AA patients demonstrate elevated erythrocyte sedimentation rates (ESR) or high sensitivity C-reactive protein (CRP) levels. CRP levels may be exceedingly high. Nerve root or cauda equina inflammation can often be, however, observed on an MRI since inflammation causes edema (swelling), displacement, and the adherence or clumping of nerve roots to each other. Limit alcohol, which can cause more problems with sleep and pain. 4. If permanent damage has occurred, surgery cannot always repair it. There are also no reliable laboratory tests or imaging test findings to definitively diagnose arachnoiditis. Drink plenty of fluids and practice regular personal hygiene to prevent urinary tract infection. {"url":"/signup-modal-props.json?lang=us"}, Radswiki T, Baba Y, Saber M, et al. Hutchinson MR, Northcutt AL, Chao LW, et al. Many persons with intraspinal canal inflammation develop the symptom profile of AA, but the diagnostic clumping of nerve roots which is necessary for a diagnosis of AA may not be evident. Maybe not. Urinary retention: the most common symptom. The cauda equina is the conglomeration of the nerve roots of the lumbar and sacral spinal nerves . Knee bending and raising the leg toward the abdomen while either lying down or standing is necessary. He is in violent pain. ", New York-Presbyterian Hospital: "Cauda Equina Syndrome.". Miserable quality of life. L3/4: Asymmetric disc bulge with minor central canal and left subarticular recess narrowing. The changing pattern of spinal arachnoiditis. Her MRI (Figure 5, C) is still abnormal. The protocol comprises 4 components: (1) control and suppression of neuroinflammation; (2) exercises to prevent adhesions; (3) pain relief; and (4) neuroprotection and neurogenesis (nerve growth) (Table 2). The most critical component of treatment is suppression and control of neuroinflammation; otherwise, AA may progress and worsen. investigating cauda equina syndrome (summary), ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. This website is the stand out source for me. Well defined hyperintense lesion within L4 vertebra body in keeping with a vertebral hemangioma. BMJ Case Rep. 2017;2017:bcr-2017-219890. Within 90 days she was put on the medical regimen shown in Table 2. Surgical decompression within 24 hours seems to have the best outcome 1,3,6. Unable to process the form. Castillo M. Neuroradiology Companion: Methods, Guidelines, and Imaging Fundamentals. Cauda equina syndrome is considered an incomplete cord syndrome, even though it occurs below the conus. Arachnoiditis from experimental myelograph with aqueous contrast media_. 2010;330(6005):783-788. They also mimic other conditions. Modic type 2 endplate changes are seen at the L4/L5 level. These can reduce swelling. Cauda equina syndrome may be caused by a herniated disk, tumor, infection, fracture, or narrowing of the spinal canal. Chew DJ, Carlstedt T, Shortland PJ. L4/5: Grade 1 retrolisthesis of L4 on L5. You cannot cut a nerve (ablate) and expect it to continue to work. Streit WJ, Mrak RE, Griffin WS. Nakano M, Matsui H, Miaki K, Yamagami T, Tsuji H. Postlaminectomy adhesion of the cauda equina. LWW. Patients with CES may experience some or all of these red flag symptoms. It is a rare but serious disorder, and a medical emergency. Propentofylline, a glial modulating agent, exhibits antiallodynic properties in a rat model of neuropathic pain. Spinal stenosis was present in 44 patients giving an incidence of abnormal nerve root distribution of 36% in this group. Gitelman A, Hishmeh S, Morelli B et al. Some patients report that pain is so excruciating that high-dose opioids are required for even a modicum of pain control. Case Discussion. At the time the article was last revised Yahya Baba had no recorded disclosures. Cauda equina syndrome can present either acutely or chronically and requires two sets of symptoms/signs 1-3: There is a host of associated symptoms and signs, which may be unilateral or bilateral and have a variable presence 1-3,6,10: radiculopathy/sciatica (unilateral or bilateral), paresthesia of lower limbs and perianal/saddle region (variable), weakness of lower limbs in a lower motor neuron pattern (variable). Many people with arachnoiditis are unable to work and have a significant disability because of constant pain. This may relate to any interval spinal intervention, infection or trauma during this period. Even with treatment, you may not retrieve full function. The diagnosis of AA is made by history, physical, and a confirmatory MRI. The cauda equina is the bundle of nerve roots located at the lower end of the spinal cord. In some individuals, CSF flow is impaired,and they may develop hydromyeliawhich should, therefore, be sought in the cord. They send and receive messages to and from your legs, feet, and pelvic organs. Water immersion is highly recommended, as it allows better stretching and pain relief. Based on CT and MRI findings, features consistent with arachnoiditis ossificans. Here's what you need to know about cauda equina syndrome. Subject charts were reviewed by a . from the American Academy of Orthopaedic Surgeons. Arachnoiditis. The MRN findings confirming the clinical suspicion of CES included thickening or clumping of cauda equina nerve roots, tethered cord, lumbosacral perineural mass lesion, and increased signal and/or thickening of sacral nerve roots with or without the presence of a focal lesion, such as a Tarlov cyst. Arachnoiditis is rare, but researchers dont know exactly how widespread it is. OCallaghan JP, Sriram K, Miller DB. Viewing 2 posts - 1 through 2 (of 2 total). The cauda equina is the continuation of these nerve roots in the lumbar and sacral region. Anatomical variant with sacralization of the L5 vertebral body. 1. 4. You'll find that both physical and emotional support is essential. Depending on the cause of your CES, you may also need high doses of corticosteroids. Urinary and/or fecal incontinence. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Severe nerve-type (neurogenic) pain may require prescription pain medication with side effects that may cause further problems. An acetazolamide based multimodal analgesic approach versus conventional pain management in patients undergoing laparoscopic living donor nephrectomy. Raghavendra V, Tanga FY, DeLeo JA. Nakano M, Matsui H, Miaki K, Tsuji H. Postlaminectomy adhesion of the cauda equina: inhibitory effects of anti-inflammatory drugs on cauda equina adhesion in rats. Following surgery, drug therapy coupled with intermittent self-catheterization can help lead to a slow, but steady, recovery of bladder and bowel function. View Frank Gaillard's current disclosures, see full revision history and disclosures, NeuroImaging 4 - Skull, Spinal cord and Cranial Nerves. In addition, some patients find that physical therapy and psychological counseling help them cope with CES. If a tumor is responsible, radiation or chemotherapy may be needed after surgery. !he read all of my issue and details and his replies really helped me in decidingi am now confident about my decision and i now totally understand the procedure thanks to the in-depth information providedthank you ever so much ! American Association of Neurological Surgeons: "Cauda Equina Syndrome (CES). Although the term cauda equina syndrome has traditionally only referred to the acute compression of the nerve roots, some practitioners have used the term chronic cauda equina syndrome when bladder and bowel dysfunction, pain, and some paraparesis coexist. In addition, cauda equina syndrome is a rare but well-recognized complication of longstanding ankylosing spondylitis. Surgery must be done quickly to prevent permanent damage, such as paralysis of the legs, loss of bladder and bowel control, sexual function, or other problems. You must be logged in to reply to this topic. WebMD does not provide medical advice, diagnosis or treatment. CES affects a bundle of nerve roots called cauda equina (Latin for horse's tail). If the pain is chronic, it may become "centralized" and radiate to other areas of the body. Stretching and range-of-motion exercises. [3] Cauda equina syndrome occurs when the nerve roots in the lumbar spine are compressed, disrupting sensation and movement. Sleep drives metabolite clearance from the adult brain. That is generally from a degenerative disc or facet. His MRI has revealed clumping of the Cauda Equina consistent with Arachnoiditis. At this juncture the author has seen success with a number of pain control regimens and agents. A number of case reports have shown linked arachnoiditis in the pathogenesis of the cauda equina syndrome of ankylosing spondylitis. As far as I can determine, the term chronic cauda equine syndrome is not due to nerve root compression but, rather, neuroinflammation of the nerve roots in the cauda equinein effect, it may be considered an alternate name for AA. Patients who develop acute arachnoiditis complain of severe back pain, leg weakness or radiculopathy, and possibly bladder impairment within 24 hours (sometimes within minutes to an hour) after the inciting event (Figure 6). It is characterized by thickening of the arachnoid membrane and dura mater adhesions that result in chronic lower back pain. J.T. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (4): 1201-1222. She was started on a 6-day methylprednisolone dose pack and a ketorolac injection (60 mg) for 3 consecutive days. Causes Their lining is fragile. For example, what may start out as mild pain with some bladder or bowel dysfunction with mild headache may progress to an inability to urinate without catheterization and lower limb paralysis.
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