Simultaneous L1-2 Bulged Disc and Mobile Spinal Schwannoma Causing Cauda Equina Syndrome: A Rare Case Report.

BACKGROUND Aside from the rarity of mobile spinal schwannomas, the coexistence of these tumors with herniated intervertebral disc is also scarce. Furthermore, cauda equina syndrome (CES), as a manifestation of intraspinal schwannomas has been reported rarely. Described here is a case of simultaneous lumbar disc bulge and mobile spinal schwannoma presented with intermittent symptoms of CES. CASE REPORT A 62-year-old man presented with severe but intermittent leg pain for 2 weeks, which later progressed to an episode of lower extremity weakness and difficulty in urination. Magnetic resonance imaging revealed an intraspinal tumor that moved in position relative to the L1-2 disc bulge on scans 6 h apart, with associated spontaneous regression in symptoms. The tumor was found to be a mobile spinal schwannoma, originated from a nerve root. A standard microdissection technique was used to remove the tumor through a spinous process-sparing unilateral approach, with complete laminectomy of L1. Use of intraoperative ultrasound facilitated the accurate tumor localization. Postoperatively, the patient no longer had symptoms. CONCLUSIONS This report presents a combination of a common spinal pathology, intervertebral disc herniation, alongside a rare condition, mobile spinal schwannoma, whose uncommon clinical manifestations, such as CES can cause irreversible neurological deficits. Surgeons need to remain vigilant of potential atypical scenarios when treating patients. Surgical treatment challenges regarding the mobility of tumors, such as accurate localization, should be addressed using intraoperative imaging to avoid wrong-level surgery. To mitigate the irreversible neurological complications, patients should receive comprehensive information for alarming signs of CES.

A rare case of spontaneous giant pneumorrachis presenting with cauda equina syndrome: a case report.

INTRODUCTION: Pneumorrachis is presence of air in the epidural space. It could be the result of trauma, barotrauma, iatrogenic or spontaneous. The pneumorrachis per se is an underdiagnosed entity as most of the patients are asymptomatic or have subclinical symptoms. The spontaneous occurrence of pneumorrachis has been reported in literature but giant spontaneous occurrence causing cauda equina syndrome has not been reported so far. CASE PRESENTATION: We report a case of 56-year-old male patient who came to our OPD on wheelchair with complains of difficulty in walking for 6 months with dribbling of urine for 2 months with on and off back pain. His perianal sensation was reduced with absent voluntary anal contraction. Imaging revealed giant air pockets in the spinal canal of L5-S1 extending upto L4-L5. It was managed surgically wherein laminectomy without fusion was done. The patient responded well to the treatment. DISCUSSION: There are many causes of pneumorrachis described in literature. Most of the cases of pneumorrachis are asymptomatic and incidentally diagnosed. With the improvement in radio-diagnostic modalities, the diagnosis of pneumorrachis can be easily established. When symptomatic, they can be managed conservatively. Those presenting with neurological deficit may require surgical intervention or other invasive intervention.

Lightning strike­induced cauda equina syndrome: a case report.

Peripheral nerve injuries after being struck by lightning have been documented. Here, we report a case of cauda equina syndrome induced by lightning. A 27-year-old man presented with numbness, a burning sensation in the saddle region, and increased urinary urgency after being struck by lightning. He had absent Achilles reflexes and paresthesia in the saddle region upon neurological examination, and magnetic resonance imaging of the spine was normal. Electrophysiological studies indicated involvement of bilateral L5, S1, and S2 myotomes and revealed cauda equina lesions. 
Peripheral nerve injury induced by lightning is rare, and the evaluation of people with neurological complaints using electromyography will help determine the true incidence.

Double Level Non-Contiguous Traumatic Lumbar Disc Herniation Presenting With Cauda Equina Syndrome: A Case Report and Literature Review.

CASE: A 52-year-old man presented with cauda equina syndrome after a motorcycle accident. Magnetic resonance imaging revealed traumatic disc herniation, at L2-L3 and L5-S1 levels without bony injury. He was managed successfully by wide laminectomy and microdiscectomy at both levels with complete neurological recovery at 2-month follow-up. CONCLUSION: With a reported incidence of 0.4%, traumatic disc herniation in the lumbar region is an uncommon occurrence that may resemble a spinal epidural hematoma in acute trauma. Although MRI may not reliably differentiate spinal epidural hematoma from disc herniation, urgent surgical intervention may be required in profound neurological deficits.

Paget Disease of Bone Harboring Bone Metastatic Neuroendocrine Cancer: A Case Report.

In this case report, we describe an uncommon case of neuroendocrine cancer of unknown origin began with cauda equina syndrome in a patient affected by Paget disease of bone (PDB). A 76-year-old man with diagnosis of PDB, without history of pain or bone deformity, developed sudden severe low back pain. Bone alkaline phosphatase was increased and MRI and whole-body scintigraphy confirmed the localization of the disease at the third vertebra of the lumbar spine. Treatment with Neridronic Acid was started, but after only 2 weeks of therapy anuria and bowel occlusion occurred together with lower limb weakness and walking impairment. Cauda equina syndrome consequent to spinal stenosis at the level of L2-L3 was diagnosed after admission to Emergency Department and the patient underwent neurosurgery for spinal medulla decompression. The histologic results showed a complete subversion of bone structure in neoplastic tissue, consistent with metastatic neuroendocrine carcinoma of unknown origin. In conclusion, low back pain in the elderly may require deep investigation to individuate rare diseases. In asymptomatic patients with apparently stable PDB, the sudden appearance of pain or neurologic symptoms may alert the clinician for the possibility of other superimposing diseases, like bone metastases.

Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers.

BACKGROUND: Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS: A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS: 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS: These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.

Chronic cauda equina syndrome decompression surgery recovery is very "bad"? Based on patient self-assessment.

BACKGROUND: Symptoms of cauda equina syndrome (CES) secondary to degenerative lumbar spine diseases are sometimes mild and tend to be ignored by patients, resulting in delayed treatment. In addition, the long-term efficacy of surgery is unclear. OBJECTIVE: To determine the predictive factors of CES and post-operative recovery in patients with symptoms lasting > 3 months. METHODS: From January 2011 to December 2020, data of 45 patients with CES secondary to lumbar disk herniation/lumbar spinal stenosis were collected from a single center. The patients had bladder, bowel or sexual dysfunction and decreased perineal sensation that lasted for > 3 months. A 2-year post-operative follow-up was conducted to evaluate recovery outcomes, which were measured by validated self-assessment questionnaires conducted by telephone and online. RESULTS: Overall, 45 CES patients (57.8% female; mean age, 56 years) were included. The duration of pre-operative CES symptoms was 79.6 weeks (range, 13-730 weeks). The incidence of saddle anesthesia before decompression was 71.1% (n = 32), bladder dysfunction 84.4% (n = 38), bowel dysfunction 62.2% (n = 28) and sexual dysfunction 64.4% (n = 29). The overall recovery rate of CES after a 2-year follow-up was 64.4%. The rates of the residual symptoms at the last follow-up were as follows: saddle anesthesia 22.2%, bladder dysfunction 33.3%, bowel dysfunction 24.4% and sexual dysfunction 48.9%. Pre-operative saddle anesthesia, overactive bladder and sexual dysfunction were risk factors for poor prognosis after decompression. CONCLUSION: CES patients with symptoms lasting > 3 months may recover after surgery. Sexual dysfunction has a high residual rate and should not be ignored during diagnosis and treatment.

Cauda equina syndrome in a patient with human immunodeficiency virus and secondary central nervous system lymphoma: a case report.

BACKGROUND: Secondary central nervous system lymphoma (SCNSL) is a known complication of immunocompromised patients with most cases involving the brain parenchyma. Reports of cauda equina syndrome (CES) caused by SCNSL are exceedingly scarce as involvement of this anatomical region is extremely uncommon. CASE PRESENTATION: We report a case of a 46-years-old, African, female patient with human immunodeficiency virus (HIV) who developed CES in the context of SCNSL. There were no blasts present in the peripheral blood smear. We provide a review of the literature, discussion of the clinical evolution of this patient and the radiological/histopathological findings. The patient ultimately responded well to induction chemotherapy and high dose methotrexate. CONCLUSION: This case report demonstrates that CES, while a rare occurrence in this clinical context, should be considered in at-risk patients especially those presenting with abnormal neurological findings. Prompt recognition may prevent permanent neurological injury and obviate the need for more invasive therapeutic interventions.

Tarlov cyst with self-healing cauda equina syndrome following combined spinal-epidural anesthesia: a case report.

BACKGROUND: Cauda Equina Syndrome (CES) after Combined Spinal-Epidural Anesthesia (CSEA) is a rare disease that most of the time need surgery to relieve spinal cord compression. CASE PRESENTATION: A 34-year-old male patient underwent a procedure for prolapse and hemorrhoids (PPH) under CSEA. Anesthesia and surgery were uneventful. However, the patient gradually experienced urinary retention, lower abdomen and back pain, changes in bowel habits and neurological dysfunction of the lower limbs when the catheter was removed. It was later determined that the patient had Tarlov cyst at the left S1 level in the sacral canal. Finally, the patient completely recovered 20 days after drug conservative therapy onset. CONCLUSION: This case suggests that CES might occur even after ordinary CSEA. The risk factors are drug neurotoxicity to ropivacaine and Tarlov cyst, which helped to accumulate ropivacaine. The development of ultrasound-guided CSEA and an ultrasound atlas of the spinal canal are required.

High-Riding Conus Medullaris Syndrome: A Case Report and Literature Review-Its Comparison with Cauda Equina Syndrome.

INTRODUCTION: Conus medullaris syndrome (CMS) is a distinctive spinal cord injury (SCI), which presents with varying degrees of upper motor neuron signs (UMNS) and lower motor neuron signs (LMNS). Herein, we present a case with a burst fracture injury at the proximal Conus Medullaris (CM). CASE PRESENTATION: A 48-year-old Taiwanese male presenting with lower back pain and paraparesis was having difficulty standing independently after a traumatic fall. An Imaging survey showed an incomplete D burst fracture of the T12 vertebra. Posterior decompression surgery was subsequently performed. However, spasticity and back pain persisted for four months after surgical intervention. Follow-up imaging with single photon emission computed tomography (SPECT) and a whole body bone scan both showed an increased uptake in the T12 vertebra. CONCLUSION: The high-riding injury site for CMS is related to a more exclusive clinical representation of UMNS. Our case's persistent UMNS and scintigraphy findings during follow-up showcase the prolonged recovery period of a UMN injury. In conclusion, our study provides a different perspective on approaching follow-up for CM injuries, namely using scientigraphy techniques to confirm localization of persistent injury during the course of post-operative rehabilitation. Furthermore, we also offered a new technique for analyzing the location of lumbosacral injuries, and that is to measure the location of the injury relative to the tip of the CM. This, along with clinical neurological examination, assesses the extent to which the UMN is involved in patients with CMS, and is possibly a notable predictive tool for clinicians for the regeneration time frame and functional outcome of patients with lumbosacral injuries in the future.

A comparison of the safety and efficacy of minimally invasive surgery versus open surgery in treating cauda equina syndrome: A systematic review and meta-analysis.

PURPOSE: To compare the safety and efficacy of minimally invasive surgery (MIS) and open surgery (OS) in treating cauda equina syndrome (CES). METHODS: A systematic literature search was conducted, searching relevant databases for studies investigating MIS and/or OS in treating CES. Pooled outcomes and their 95% confidence intervals (CIs) were meta-analyzed via random-effects models. RESULTS: Ten studies were included in the meta-analysis. Pooled mean operation times were shorter for MIS (75.4 min; 95 %CI: 40.8, 110.0) than OS (155.1 min; 121.3, 188.9). Similarly, mean hospital stay was shorter for MIS (4.08 days; 2.77, 5.39 vs. 8.85 days; 6.56, 11.13). Mean blood loss was smaller for MIS (71.7 mL; 0, 154.5 vs. 366.5; 119.1, 614.0). Mean post-op lumbar/back visual analogue scale (VAS) score was lower for MIS (3.65; 2.75, 4.56 vs. 5.80; 4.55, 7.05). Mean post-op leg VAS score was 1.27 (0.41, 21.4) for MIS and 1.29 (0.47, 2.12) for OS. Mean complete bladder recovery rate was 81.0% (55.0%, 94.0%) for MIS and 75.0% (44.0%, 92.0%) for OS. Mean complete motor recovery rate was larger for MIS (70.0%; 48.0, 85.0 vs. 42.0%; 34.0, 51.0). Mean percentages of "excellent" patient outcomes were equal for MIS (64.0%; 48.0%, 77.0%) and OS (64.0%; 22.0%, 92.0%). CONCLUSION: MIS for CES was associated with reduced operative time, length of stay, and blood loss, compared to OS. MIS was also associated with better post-operative lumbar/back and leg VAS scores and complete motor and bladder recovery rates. MIS and OS produced an equal average percentage of "excellent" patient outcomes.

Intraoperative Ultrasound and Findings of Lumbar Intradural Disk Herniation Causing Cauda Equina Syndrome.

Intradural lumbar disk herniation (ILDH) is a rare variant and accounts for 0.33%-1.5% of lumbar disk herniations. Although clues exist on preoperative imaging, they remain subtle and most cases of ILDH are diagnosed intraoperatively. Intraoperative ultrasound is a useful adjunct in diagnosing and managing ILDH. We present a case to demonstrate the features of an intradural herniated disk on ultrasound imaging and highlight the utility of intraoperative ultrasonography in establishing diagnosis, guiding dural opening, and confirming adequate nerve root decompression following diskectomy.

Cauda Equina Syndrome in a Military Personnel: A Case Report.

Cauda equina syndrome is a rare but severe neuro-spinal disorder commonly caused due to lumbar disc herniation, which occurs mostly at lower levels of L4-S1. We report a case of 38-year-old male soldier deployed on a foreign mission who presented to a level 1 military hospital 4 months back with complaints of decreased movement of bilateral lower limbs and severe low back pain radiating to the right lower limb for 2 hours. He was referred to a higher centre and diagnosed with cauda equina syndrome due to massive disc herniation at levels L2-L3. He underwent laminotomy and discectomy of the extruded intervertebral disc after 48 hours. On subsequent follow-up, his bladder and lower limbs sensations were normal however, he had bowel incontinence, hypotonia, hyporeflexia, and no significant improvement in power. Hence, early diagnosis, referral, and timely intervention affect the outcomes in a cauda equina syndrome patient. Keywords: case reports; cauda equina syndrome; disc herniation; low back pain; military personnel.

Lumbar Disc Herniation: Diagnosis and Management.

Lumbar disc herniations are common causes of lower back pain, neurological dysfunction, and buttock/leg pain. Herniation refers to the displacement of the nucleus pulposus of the intervertebral disc through the annulus fibrosus, thereby causing pressure on the neural elements. The sequalae of lumbar disc herniations range in severity from mild low back and buttock pain to severe cases of inability to ambulate and cauda equina syndrome. Diagnosis is achieved with a thorough history and physical examination along with advanced imaging. Treatment plans are dictated by corresponding patient symptoms and examination findings with their imaging. Most patients can experience relief with nonsurgical measures. However, if symptoms persist or worsen, surgery may be appropriate.

Non-surgical treatment of giant tumor-like lumbar disc herniation based on enhanced MRI: A case series.

RATIONALE: In recent clinical follow-up, it has been vertified that resorption in lumbar disc herniation (LDH) could be of great curative effect in non-surgical treatment for LDH. However, reports of resorption in giant tumor-like LDH are rarely mentioned due to its risk of irreversible neurological damage which could be caused by long-term non-surgical treatment. In our clinical observations, we have found that enhanced MRI helps to distinguish LDH from intradural tumours and to predict the probability of resorption in LDH. We analyzed 8 patients with giant tumor-like LDH who underwent non-surgical treatment, and these patients had resorption during follow-up. All patients were examined with enhanced MRI before treatment, and the type of "bull's eye" sign classification was determined by images. The MRI protrusion volume(VP), resorption rate(HR%) and JOA score of patients at the first visit and the last follow-up were recorded. PATIENT CONCERNS: 8 patients of Han ethnicity were admitted to the department of orthopedic complaining of low back pain for 1week to 12months. They were diagnosed with giant tumor-like LDH by enhanced MRI. DIAGNOSES: These patients were diagnosed with giant tumor-like LDH. INTERVENTIONS: We adopted a non-surgical treatment plan for the patients, including taking oral non-steroidal anti-inflammatory agents and performing rehabilitation exercise. In consideration of the risk of irreversible neurological damage, patients were closely observed during treatment and follow-up. Once the following conditions occur, surgical treatment is required immediately: The symptoms are not signifcantly relieved after 3 to 6 months of non-surgical treatment; The symptoms are aggravated by non-surgica treatment; The clinical manifestations of cauda equina syndrome. OUTCOMES: After treated with oral non-steroidal anti-inflammatory agents and rehabilitation exercise, the resorption was accompanied by clinical symptom relief. No neurological damage occurred in all patients, and the clinical symptoms did not recur in the subsequent follow-up. LESSONS: Clinicians should fully consider the possibility of resorption prior to surgical treatment in patients with giant LDH. We can predict the probability of resorption in patients with giant LDH based on enhanced MRI. For patients with a high probability of resorption, we can choose non-surgical treatment in the absence of progressive neurological impairment and cauda equina syndrome.

Cauda equina syndrome by extrusion of lumbar disc after lumbar sympathetic neurolysis.

A 56-year-old woman experienced persistent excruciating pain with peroneal nerve injury in the anterior aspect of the lower leg after knee surgery. In our pain clinic, we diagnosed the patient with complex regional pain syndrome and performed lumbar sympathetic neurolysis (LSN) with absolute alcohol at the 3rd lumbar vertebra (L3). After the next follow-up, she complained of continuous dull low back pain, anal dysregulation, and fecal incontinence. We performed magnetic resonance imaging (MRI) to rule out other existing pathologies of back pain. On MRI, the nucleus pulposus was moderately extruded to the central zone with inferior sequestration at L2/3, and moderate central canal stenosis was observed at L2/3. She underwent partial laminectomy with discectomy at L2 level. We were not sure of the cause of disc herniation, but we strongly suspected that LSN at the L3 vertebral level was related to the pathology. Therefore, we discuss this unusual case.

Cauda equina syndrome from intradural metastasis of a non-neural tumor: case report and review of literature.

BACKGROUND: Cauda equina syndrome (CES) is a challenging condition and it can be caused by variable entities. Leptomeningeal carcinomatosis (LC) is a multifocal seeding of the leptomeninges by malignant cells and it is observed in 1-8% of patients with solid tumors. Diagnosis of intradural metastases of the cauda equina is often delayed due to the non-specific characteristics of this condition but also to the delay of presentation of many patients. Cauda equina metastases usually occur in advanced cancers, but rarely can be the first presentation of disease. CASE DESCRIPTION: A 63-year-old man presented with 6 months history of low back pain and 20 d history of bilateral sciatica, hypoesthesia of the legs and the saddle, flaccid paraparesis and bowel incontinence determine by multiple nodular small lesions on the entire cauda equina with contrast-enhancement. Total-body CT showed a millimetric lesion at the lung. The patient underwent L2-L5 laminectomy and subtotal removal and histological examination showed a small cell lung carcinoma metastasis. CONCLUSIONS: In the literature, 54 cases of CES from non-CNS tumor metastasis are described. The diagnosis is challenging, back pain, with or without irradiation to the lower limbs, is the most frequently reported disturbance. In about 30% of patients there is no known malignancy and CES is the first clinical presentation. Treatment of choice is surgery, followed by radiotherapy and less frequently adjuvant chemotherapy. The surgical removal is almost always incomplete and functional outcome is often not satisfactory. Prognosis is poor.

Facet joint cyst haematoma: a rare cause of cauda equina syndrome.

Facet joint cysts are a feature of lumbar spondylosis and are an uncommon cause of radiculopathy. Facet joint cyst haematoma is a very rare entity and has previously been reported as a subacute cause of leg pain, back pain, sensory deficit and lower limb weakness. We present the unique case of facet joint cyst haematoma presenting as cauda equina syndrome. An 81 year old lady presented with a 7 day history of back pain and left foot drop, a 1 day history of perineal numbness and urinary retention with absent rectal tone, perianal anaesthesia and left leg hypoaesthesia. Emergency MRI scan demonstrated spinal canal stenosis as the aetiology of her cauda equina syndrome. She was taken to theatre for emergency lumbar decompression. At operation a facet joint haematoma compressing the cauda equina was found and extirpated with complete resolution of symptoms. In this case, the aetiology of cauda equina compression was not demonstrated effectively on pre-operative MRI scanning.

Surgical decompressions for cauda equina syndrome during COVID-19.

BACKGROUND: The novel coronarvirus disease (COVID-19) has had a major impact on provision of spinal neurosurgery across the world, especially in the UK, with a significant fall in operating and patient volumes, and elective clinical activities. It is unclear whether the pandemic has affected the volume of urgent spinal procedures in the UK, especially surgical decompressions for cauda equina syndrome (CES). METHODS: Therefore, we conducted a retrospective analysis of theatre records and electronic operation notes at our institution to identify all procedures performed for CES before (December 2019 to February 2020) and during (March 2020 to May 2020) the COVID-19 pandemic. Statistical analyses were performed on SPSS v22 (IBM). RESULTS: Forty-four patients underwent surgical decompressions during the study period. Over half (54.5%) were female and the median age was 45 years (range = 22-78 years). Three in four procedures were performed at L4-5 and L5-S1 levels (79.5%). There was no statistically significant difference in the number of decompressions performed each month [χ2(5)=1.818; p = 0.874]. On the other hand, the number of referrals for suspected or confirmed CES fell by 81.8% between December 2019 and April 2020. CONCLUSIONS: Our results did not show any statistically significant decline in the volume of surgical decompressions performed for CES despite the considerable fall in electronic referrals for CES and degenerative spinal conditions. This suggests that patients with critical neurological symptoms continued to present and were treated appropriately despite the restrictions imposed on spinal surgeons during the pandemic.

Cauda equina syndrome after use of dural sealant in revision lumbar decompression surgery.

OBJECTIVE: We report a case of cauda equina syndrome related to the use of fibrin glue dural sealant "TISSEEL". BACKGROUND: Incidental durotomy (ID) is not uncommon in revision spinal surgery. Augmentation of the dural repair after primary closure is gaining popularity. The use of dural sealants is not risk-free. METHOD: A 65-year old man who underwent revision lumbar decompression surgery developed postoperative cauda equina syndrome. He had urinary retention, bilateral leg pain and perianal numbness on the third postoperative day. We believe this complication was related to the use of fibrin glue to manage an ID. RESULT: After the urgent surgical removal of the fibrin glue patch, the patient fully recovered with no residual neurological deficit. CONCLUSION: Cauda equina syndrome development is a potential complication after the use of fibrin glue to augment intraoperative ID. Surgeons should be aware of this potential risk so it can be managed in a timely fashion.