67 year old gentleman today mr smith who's a retired teacher.

he presents today with

a two-month history of noticing blood in the stools which he reports is very dark red
and mixed in with the stools.he also notes that his stools have sometimes been very
dark and very very smelly compared to normal. also note is he does mention he's
lost six kilos over the last two months. he mentions that he feels quite constipated
compared to normal and he also reports a recent history of tenesmus.he doesn't
smoke but he does drink alcohol roughly once a week .um he's not particularly
worried about all of this the main reason why he's here is his wife was worried and
told him to come in. my relevant negative findings are that reassuringly he's reports
no vomiting and no problems passing urine. So putting all this together my top
differential here would be colorectal cancer.other differentials that are important
to consider but probably less likely would be things like colorectal polyps as well as
constipation. so regarding the colorectal cancer i think the history of tenesmus is vital
i think it points more towards a left-sided low-lying tumor. possible complications of
colorectal cancer that are really important to be aware of and things i'd want to
exclude would be toxic megacolon as well as bowel perforation
Now if you cut the spinal column in half lengthwise you can see that all the vertebral
foramina together form the vertebral, or the spinal canal, which is occupied by the
spinal cord.

The spinal cord is connected to the brain and travels through the spinal canal to the
second lumbar vertebra, where it ends in a cone, called conus medullaris. There are
31 pairs of nerves originating from the spinal cord called spinal nerves; there
are 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal.

Each nerve leaves the spinal canal through the corresponding intervertebral
foramen,which are openings between two adjacent vertebrae.Since the spinal cord is
shorter than the spinal canal, the nerves of the lumbar, sacral and coccygeal regions
have to travel down the spinal canal to reach their corresponding openings, forming
a nerve bundle below the spinal cord called the cauda equina.

These nerves carry motor innervation for the genitals, both internal and external anal
sphincter, detrusor vesicae, which is a muscle in the bladder that contracts during
urination, and muscles of the leg.They are in charge of the knee and ankle reflexes.
Skin sensations of the legs and pelvis are also carried by these nerves.
Cauda equina syndrome is caused by compression, trauma, or damage to multiple
nerves of the cauda equina.
Large lumbar disc herniation is the most common cause of cauda equina syndrome.
And poor posture, traumas, physical activity, and strong rotational movement can
cause herniations where the intervertebral disc bulges out and compress the nerves
or spinal cord.
This is similar to sciatica, but the herination is usually larger, and more nerves are
compressed,including those that control the bladder and reproductive organs.

Compression can also be caused by spinal stenosis which is the narrowing of the
vertebral foramenin the lumbar vertebrae.It can be congenital, meaning that the
person is born with it, or acquired, usually due to degenerative disorders like
ankylosing spondylitis, where the bones remodel causing intervertebral discs
ossification, and the narrowing of the spinal canal.

Another cause is spondylolisthesis where a lumbar vertebrae is displaced.This can

be caused by trauma, surgery or degenerative spinal disease. The most common
type of lumbar spondylolisthesis is anterolisthesis, where a vertebra movesforward
and narrows the spinal canal, causing compression of the nerves.

Finally, any trauma to the spine, like the one caused by a car crash, gunshot, etc. can
lead to nerve damage or compression directly, or by causing bleeding inside the
spinal canal,causing compression via hematomas.Finally any growths within the
spinal canal like tumors, cysts, or abscesses can cause compression on the spinal
cord and nerves.
Symptoms of cauda equina include decreased bowel and bladder control due to a
decreased tone of anal sphincters and muscle wall of the bladder and decreased
sexual function.

It can also cause saddle anesthesia, which is a loss of sensation in the saddle area,
which includes the buttocks, inner surface of the thigh and perineum. One or both
legs can be impaired by muscle weakness, loss of knee and ankle reflexes,and even
paraplegia, which is when the affected person loses all feeling and muscle control in
the legs.Sometimes, there can be sciatic pain, which is a sharp pain going down the
back and leg.