Aneurysmal subarachnoid hemorrhage complicating spinal subarachnoid hematoma causing acute cauda equina syndrome: a case report.

BACKGROUND: Spinal subarachnoid hematoma (SSH) is a known but rare entity that can cause cauda equina compression. The occurrence of SSH associated with aneurysmal subarachnoid hemorrhage has rarely been described in the literature. CASE PRESENTATION: A 56-year-old woman presented with subarachnoid hemorrhage secondary to a ruptured middle cerebral artery aneurysm and was managed with coiling embolization without stent assistance. There was no history of either lumbar puncture or the use of anticoagulants. The patient developed severe lumbago radiating to bilateral legs nine days after the procedure. Subsequent magnetic resonance imaging demonstrated a SSH extending from L5 to S2 and wrapping around the cauda equina. The patient was treated with intravenous methylprednisolone (250 mg/day) for four consecutive days, followed by a taper of oral prednisolone (20 mg/day) until complete recovery. Magnetic resonance imaging at one month follow-up revealed complete resolution of the SSH. CONCLUSIONS: Here, we report a case of acute cauda equina syndrome caused by a SSH after aneurysmal subarachnoid hemorrhage, which will facilitate timely intervention of patients with this disorder.

Triangular Osteosynthesis as a Treatment of Lumbopelvic Dissociation with Acute Cauda Equina Syndrome in an 11-Year-Old Patient.

This case offers a safe and effective method for treating lumbopelvic dissociation in a pediatric patient with cauda equina syndrome using a triangular osteosynthesis construct. After a high-speed accident, an 11-year-old girl was admitted to the hospital with bowel and bladder incontinence and bilateral lower extremity weakness. The orthopaedic trauma and spine teams elected for surgical treatment with a triangular osteosynthesis construct, a procedure usually reserved for adults. The surgery was uncomplicated, and the patient experienced complete resolution of her preoperative symptoms. She is doing well over 1-year postoperatively, with full neurologic recovery, maintained reduction, bony healing, and subsequent implant removal. To our knowledge, this is the youngest reported case of lumbopelvic dissociation treated in this manner and represents a viable treatment option.

Association of Tarlov cyst with cauda equina syndrome and spinal cord infarction following caudal epidural block: A case report.

RATIONALE: Caudal epidural block (CEB), which injects drugs into the epidural space through a sacral hiatus, is considered a safer alternative to other approaches. Serious complications, such as cauda equina syndrome or spinal cord infarction, have been reported very rarely, but their coexistence after CEB, which may be related to the ruptured perineural cyst, also known as a Tarlov cyst, was not reported. PATIENT CONCERNS: A 40-year-old male patient presented with bilateral lower extremity radicular pain. CEB was performed without image guidance. The patient exhibited sensory deficits below L2, no motor function (0-grade), hypotonic deep tendon reflexes, and no pathological reflexes. DIAGNOSES: Spinal cord infarction, cauda equina syndrome, and sacral level perineural cyst with hemorrhage. INTERVENTION: High doses of steroids and rehabilitation were performed. OUTCOMES: The patient was discharged after 28 days with persistent bilateral leg paralysis and sensory deficits below the L2 level. The patient demonstrated no neurological improvement. LESSONS: Magnetic resonance imaging, including the sacral area, should be performed before performing CEB, to confirm the presence of a perineural cyst.

[Transverse myelitis and cauda equina syndrome followed by varicella in a patient with varicella-zoster virus infection].

A 74-year-old man was admitted to our hospital with complaints of weakness in the lower extremities, urinary retention for 10 days, and generalized vesicular rash for 7 days. Spinal magnetic resonance imaging showed contrast enhancement at the Th12-L1 level of the spinal cord and cauda equina. Serum and cerebrospinal fluid varicella-zoster virus (VZV)-immunoglobulin (Ig) G antibody titers were markedly elevated, and VZV-IgM was detected in cerebrospinal fluid. The patient was diagnosed with VZV transverse myelitis and cauda equina syndrome with subsequent varicella and was treated with acyclovir and prednisolone. Two months later, muscle weakness, and dysuria had almost completely resolved. We hypothesize that latent VZV in the ganglia reactivated and caused transverse myelitis, which subsequently spread to the body via the bloodstream, resulting in the development of varicella.

Stercoral Ulcer Presenting in a Patient with Cauda Equina Syndrome Secondary to Postoperative Epidural Hematoma.

Chronic constipation can lead to fecal impaction in the large bowel, which can cause pressure necrosis followed by perforation, known as a stercoral ulcer. In extensive posterior thoracolumbar surgery, a long operation time, large blood loss, and perioperative narcotic use may aggravate constipation. Moreover, sacral root palsy due to cauda equina syndrome (CES) can lead to the deterioration of fecal impaction. This report describes the case of a 77-year-old woman with CES who presented with saddle anesthesia, neurogenic bladder, bowel incontinence, and paraplegia. Five days prior, she had undergone extended posterior lumbar interbody fusion from L1 to L5. Lumbar magnetic resonance imaging (MRI) showed an extended epidural hematoma. After urgent neural decompression, she gradually recovered from the saddle anesthesia, leg pain, and paraplegia over 3 weeks. Thereafter, the patient suddenly developed massive hematochezia and hemorrhagic shock. Urgent colonoscopy was performed, and a stercoral ulcer in the sigmoid colon was diagnosed. After 4 weeks of intensive care for hemorrhagic shock, pneumonia, and systemic sepsis, the patient was transferred to a general ward for intensive rehabilitation. One year after the operation, she was able to walk with assistance, and her urinary and bowel incontinence completely recovered. Chronic constipation, a common clinical problem, can sometimes cause relatively obscure but potentially life-threatening complications such as stercoral ulceration. Possible factors including advanced age, extensive spinal surgeries, prolonged operation time, significant blood loss, perioperative narcotic use, and the presence of spinal cord injury might contribute to the development of this condition. It highlights the importance of recognizing the potential development of stercoral ulcers in patients with CES and emphasizes the need for prompt diagnosis and management to avert catastrophic complications.

[Long-term results and predictors of postoperative outcomes in patients with cauda equina syndrome following degenerative lumbar spine disease]. / Otdalennye rezul'taty i faktory, vliyayushchie na iskhod khirurgicheskogo lecheniya sindroma konskogo khvosta, obuslovlennogo degenerativnym zabolevaniem poyasnichnogo otdela pozvonochnika.

Cauda equina syndrome (CES) associated with acute disc extrusion or spinal stenosis often requires emergency surgery. Analysis of the Pubmed, Medline and eLibrary databases revealed a few studies devoted to long-term postoperative outcomes in patients with CES caused by degenerative spine disease. OBJECTIVE: To evaluate long-term postoperative results and predictors of clinical and neurological outcomes in patients with CES caused by degenerative lumbar spine disease. MATERIAL AND METHODS. D: Ecompressive and decompressive-stabilizing procedures were performed in 211 patients with CES caused by degenerative lumbar spine disease between 2000 and 2020. Long-term clinical parameters were available in 174 patients with mean follow-up period of 7 years. Sixty-eight patients had unsatisfactory postoperative outcomes. We assessed postoperative clinical and neurological outcomes in patients with CES and predictors of these outcomes. RESULTS: We identified the following predictors of clinical and neurological outcomes using binary logistic regression model: period between clinical manifestation and surgery >48 hours, preoperative neurological impairment, spinal canal diameter, surgical procedure, dimension of herniated disc, ASA score and long-term postoperative analgesia with narcotic analgesics. CONCLUSION: Preoperative planning and possible correction of the above-mentioned risk factors will potentially improve postoperative outcomes in patients with CES caused by degenerative lumbar spine disease.

Cauda Equina Syndrome Caused by Intradural Bone Graft Materials After Endoscopic Lumbar Fusion.

A 53-year-old man presented to the emergency department with severe lower back pain, saddle anesthesia, and urinary dysfunction. He had undergone endoscopic lumbar interbody fusion for highly migrated lumbar disk herniation and lumbar instability 10 days ago. Emergency computed tomography showed that the bone graft materials had migrated to the sacral canal, and a mass with low intensity was seen located at the end of the dural cavity on T2-weighted magnetic resonance imaging. It was suspected that the bone graft materials had migrated into the dural cavity at the operative level and fallen into the end of the dural cavity due to gravity, causing acute cauda equina syndrome (CES). After emergency durotomy, the bone graft materials were completely removed. At the 18-month follow-up, the patient recovered without further complications. This procedure resulted in a rare case of CES caused by intradural bone graft after endoscopic lumbar interbody fusion. Spine surgeons should be aware of this rare but potentially dangerous complication, especially in water-based endoscopic lumbar interbody fusion. This case report shows that early recognition and prompt treatment can significantly improve the symptoms of CES, including saddle numbness and bladder dysfunction. [Orthopedics. 2023;46(6):e384-e386.].

Neoplastic malignant cord compression mimicking low back pain: A case report.

BACKGROUND: The point prevalence of Cauda Equina Syndrome (CES) as a cause of Low Back Pain (LBP) is estimated at 0.04% in primary care, and it is reported as a complication in about 2% of patients with disc herniation. Compression of the cauda equina usually occurs as a result of disc prolapse. However, CES may be caused by any space-occupying lesion, including spinal stenosis, neoplasms, cysts, infection, and osteophytes. First contact physiotherapists may encounter patients with early CES, as the clinical presentation of CES can mimic non-specific LBP. CASE PRESENTATION: This case report presents the medical history, diagnostic tests and relevant clinical data of a 52-year-old man complaining of LBP. The patient's medical history, his symptoms and the clinical findings led to the identification of a number of red flags (i.e. risk factors) suggestive of a non-musculoskeletal condition. The patient was referred to the emergency department for further investigation. Having undergone several diagnostic tests, the patient was diagnosed with CES due to malignancy. CONCLUSIONS: This case report highlights the importance of differential screening throughout the treatment period, in order to identify red flags that warrant further investigation and a referral to an appropriate specialist. Physiotherapy screening should include clinical reasoning, careful analysis of clinical presentation and symptom progression, in addition to appropriate referral for medical assessment and diagnostic imaging, if necessary.

Rates of Future Lumbar Fusion in Patients with Cauda Equina Syndrome Treated With Decompression.

INTRODUCTION: The long-term risk of conversion to lumbar fusion is ill-defined for patients with cauda equina syndrome (CES) treated with decompression. This study aimed to identify the rates of fusion in patients with CES and compare those rates with a matched lumbar spinal stenosis (LSS) group. METHODS: Patients with CES who underwent decompression were identified in a national database and matched to control patients with LSS. The rates of conversion to fusion were identified and compared. Multivariate logistic regression analysis identified independently associated risk factors. A subanalysis was conducted after stratifying by timing between CES diagnosis and decompression. RESULTS: The rate of lumbar fusion in the CES cohort was 3.6% after 1 year, 6.7% after 3 years, and 7.8% after 5 years, significantly higher than the LSS control group at all time points (1 year: 1.6%, P = 0.001; 3 years: 3.0%, P < 0.001; 5 years: 3.8%, P < 0.001). CES was independently associated with increased risk of conversion to fusion (odds ratio: 2.13; 95% confidence interval: 1.56 to 2.97; P < 0.001). Surgical timing was not associated with risk of conversion to fusion. CONCLUSIONS: After 5 years, 7.8% of patients with CES underwent fusion, a markedly higher rate compared with patients with LSS. Counseling patients with CES on this increased risk of future surgery is important for patient education and satisfaction.

Chronic spontaneous epidural hematoma in the lumbar spine with cauda equina syndrome and severe vertebral scalloping mimicking a spinal tumor: a case report.

BACKGROUND: Chronic spinal epidural hematomas (SEHs) are rare clinical entities. SEH with vertebral scalloping is extremely rare, with only a few cases having been reported to date. We report a unique case of spontaneous chronic SEH in the lumbar spine with severe vertebral scalloping mimicking an epidural tumor. CASE PRESENTATION: A 71-year-old man presented with a 2-month history of lumbar pain and a 3-week history of paresthesia and pain in the right lower extremity, hypesthesia in the perineal and perianal regions, and bladder dysfunction. Computed tomography following myelography revealed an epidural mass lesion on the right side that compressed the dural sac and was associated with severe bony scalloping on the posterior wall of the L4 vertebral body. Magnetic resonance imaging (MRI) on T1- and T2-weighted images revealed a space-occupying lesion with heterogeneous intensity, and T1-gadolinium images showed an intralesional heterogeneous enhancement effect. A tumoral lesion in the spinal canal was suspected, based on preoperative imaging; therefore, a total spinal tumor resection was planned. Intraoperative findings revealed that the brownish lesion adhered to the dura and epidural tissues in the spinal canal, and the space-occupying mass in the scalloped cavity of the posterior wall of the L4 vertebra was encapsulated in red-brownish soft tissues. The lesion was totally resected in a piecemeal fashion, and pathological examination revealed a mixture of tissues that contained a relatively new hematoma with hemoglobin, as well as an obsolete hematoma with hemosiderin and amyloid deposits. The mass was diagnosed as a chronic epidural hematoma with recurrent hemorrhage. The postoperative course was uneventful, and the preoperative neurological symptoms immediately improved. CONCLUSIONS: The preoperative diagnosis of chronic SEHs is challenging, as MRI results may not be conclusive, particularly in patients with scalloping of bony structures. Thus, chronic SEHs should be considered as a differential diagnosis in cases of suspected tumoral lesions in the spinal canal. To the best of our knowledge, this is the first reported case of acute exacerbation of chronic SEH with cauda equina syndrome and severe vertebral scalloping.

Cauda equina syndrome after unilateral medial branch blocks of the lower lumbar zygapophyseal joints.

Medial branch blockade of the lumbar facet joints is widely performed and generally accepted as a safe intervention. We present a case of neurological damage following a medial branch blockade with local anesthetic and steroid. A patient suffering from chronic low back pain radiating to the buttocks and thighs underwent nine medial branch blockades over a few years. Three months after successful back surgery to remove a herniated L2-3 disk, the pain recurred, and left L3-4 , L4-5, and L5 -S1  medial branch blocks were performed under fluoroscopy. Immediately following the procedure, the patient developed paraparesis in both legs, loss of pinprick but preserved fine touch sensation, proprioception, and sphincter sensory and motor function. MRI showed ischemic lesions of the cauda equina. Direct needle trauma was discounted as a cause, due to the bilateral neurological deficit, plus the lack of pain during the procedure. Particulate steroid preparations can form aggregates, which may embolize and block small terminal arteries, causing neurological damage. Although the patient received nine sets of injections uneventfully during the previous 36 months, this procedure took place 3 months following spinal surgery. This rare, but catastrophic case of cauda equina syndrome occurred following L3-4 , L4-5 , and L5 -S1  medial branch blockades 3 months after spinal surgery, which is believed to be caused by accidental intra-arterial injection of particulate methylprednisolone, with consequent aggregates causing blockage and ensuing ischemia. Therefore we suggest particulate steroid preparations should not be used in axial spinal injection.

Lumbar decompression surgery for cauda equina syndrome - comparison of complication rates between daytime and overnight operating.

PURPOSE: To investigate the incidence of complications from lumbar decompression ± discectomy surgery for cauda equina syndrome (CES), assessing whether time of day is associated with a change in the incidence of complications. METHODS: Electronic clinical and operative notes for all lumbar decompression operations undertaken at our institution for CES over a 2-year time period were retrospectively reviewed. "Overnight" surgery was defined as any surgery occurring between 18:00 and 08:00 on any day. Clinicopathological characteristics, surgical technique, and peri/post-operative complications were recorded. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals. RESULTS: A total of 81 lumbar decompression operations were performed in the 2-year period and analysed. A total of 29 (36%) operations occurred overnight. Complete CES (CESR) was seen in 13 cases (16%) in total, 7 of whom underwent surgery during the day. Exactly 27 complications occurred in 24 (30%) patients. The most frequently occurring complication was a dural tear (n = 21, 26%), followed by post-operative haematoma, infection, and residual disc. Complication rates in the CESR cohort (54%) were significantly greater than in the CES incomplete (CESI) cohort (25%) (p = 0.04). On multivariable analysis, overnight surgery was independently associated with a significantly increased complication rate (OR 2.83, CI 1.02-7.89). CONCLUSIONS: Lumbar decompressions performed overnight for CES were more than twice as likely to suffer a complication, in comparison to those performed within daytime hours. Our study suggests that out-of-hours operating, particularly at night, must be clinically justified and should not be influenced by day-time operating capacity.

Hodgkin Lymphoma Presenting With Spinal Cord Compression: Challenges for Diagnosis and Initial Management.

Hodgkin lymphoma (HL) can present with extra-nodal disease, but spinal cord compression is exceptionally rare. We describe a 15-year-old presenting with hip/back pain with normal initial examination. Persistent pain and raised inflammatory markers prompted further investigation with MRI, which revealed an epidural mass causing spinal cord compression. On examination, there was no palpable lymphadenopathy or cauda equina syndrome, but absent lower limb reflexes were noted. Following multidisciplinary discussion, it was determined that cauda equina syndrome was imminent and therefore surgical debulking was undertaken, both to prevent this complication and establish a diagnosis. At surgery, the tumor was highly vascular. Frozen section confirmed lesional material. Following surgery, and given the frozen section findings, a short course of steroids was commenced to reduce any peri-surgical edema. Unfortunately, histopathology was ultimately non-diagnostic, due to failure of immunohistochemistry on technically challenging material. Consequently, ultrasound-guided excision biopsy of a (non-palpable) cervical lymph node was performed five days later; histopathology showed typical effacement of the normal architecture and a conspicuous population of CD15/CD30-positive larger pale cells present, confirming nodular sclerosis classic HL, despite recent steroids. We review the available literature for HL presenting with spinal cord compression and describe the challenges for diagnosis and initial management in such cases.

Factors affecting urinary outcome after delayed decompression in complete cauda equina syndrome: "A regression model study".

PURPOSE: To evaluate the recovery of urinary functions and the factors predicting urinary recovery, following delayed decompression in complete cauda equina syndrome (CESR) secondary to Lumbar disc herniation (LDH). METHODS: Retrospective study evaluated 19 cases of CESR due to single-level LDH, all presenting beyond 72 h. Mean delay in decompression was 11.16 ± 7.59 days and follow-up of 31.71 ± 13.90 months. Urinary outcomes were analysed on two scales, a 4-tier ordinal and a dichotomous scale. Logistic regression analysis was used for various predictors including delay in decompression, age, sex, radiation, level of LDH, motor deficits, type and severity of presentation. Time taken to full recovery was correlated with a delay in decompression. using Spearman-correlation. RESULTS: Optimal recovery was seen in 73.7% patients and time to full recovery was moderately correlated with a delay in decompression (r = 0.580, p = 0.030). For those with optimal bladder recovery, mean recovery time was 7.43 ± 5.33 months. Time to decompression and other evaluated factors were not found contributory to urinary outcomes on either scales. Three (15.8%) patients had excellent, 11 (57.9%) had good, while 3 (15.8%) and 2 (10.5%) had fair and poor outcomes respectively. CONCLUSIONS: Occurrence of CESR is not a point of no-return and complete recovery of urinary functions occur even after delayed decompression. Longer delay leads to slower recovery but it is not associated with the extent of recovery. Since time to decompression is positively correlated with time to full recovery, early surgery is still advised in the next available optimal operative setting. LEVEL OF EVIDENCE: IV.

Acute bilateral foot drop with or without cauda equina syndrome-a case series.

INTRODUCTION: Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded. METHODS: Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery. RESULTS: Seven patients are presented. The mean age at presentation was 52.1 years (range 41-66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other. CONCLUSION: When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.

Scan-Negative Cauda Equina Syndrome: A Prospective Cohort Study.

OBJECTIVE: To describe clinical features relevant to diagnosis, mechanism, and etiology in patients with "scan-negative" cauda equina syndrome (CES). METHODS: We carried out a prospective study of consecutive patients presenting with the clinical features of CES to a regional neurosurgery center comprising semi-structured interview and questionnaires investigating presenting symptoms, neurologic examination, psychiatric and functional disorder comorbidity, bladder/bowel/sexual function, distress, and disability. RESULTS: A total of 198 patients presented consecutively over 28 months. A total of 47 were diagnosed with scan-positive CES (mean age 48 years, 43% female). A total of 76 mixed category patients had nerve root compression/displacement without CES compression (mean age 46 years, 71% female) and 61 patients had scan-negative CES (mean age 40 years, 77% female). An alternative neurologic cause of CES emerged in 14/198 patients during admission and 4/151 patients with mean duration 25 months follow-up. Patients with scan-negative CES had more positive clinical signs of a functional neurologic disorder (11% scan-positive CES vs 34% mixed and 68% scan-negative, p < 0.0001), were more likely to describe their current back pain as worst ever (41% vs 46% and 70%, p = 0.005), and were more likely to have symptoms of a panic attack at onset (37% vs 57% and 70%, p = 0.001). Patients with scan-positive CES were more likely to have reduced/absent bilateral ankle jerks (78% vs 30% and 12%, p < 0.0001). There was no significant difference between groups in the frequency of reduced anal tone and urinary retention. CONCLUSION: The first well-phenotyped, prospective study of scan-negative CES supports a model in which acute pain, medication, and mechanisms overlapping with functional neurologic disorders may be relevant.

First experience with ATOMS system implant in neurogenic stress urinary incontinence.

AIM: To evaluate efficacy and safety of ATOMS implant in neurogenic patients with stress incontinence performing clean intermittent catheterization (CIC). METHODS: We included all patients with neurogenic sacral/subsacral lesion and stress urinary incontinence, treated with ATOMS implant between January 2018 and March 2019. All patients received anamnesis, 24-hour pad test and pad count, physical examination, video urodynamic evaluation, Qualiveen questionnaire. All patients were followed up at 12 months after implantation. Patients were considered "continent" when dry or when wearing a security pad (social continence). RESULTS: We treated eight male patients with a median age of 25 years, four affected by myelomeningocele, and four by cauda equine syndrome. The median preoperative 24-hour pad test was 225 g (interquartile range [IQR]: 180-275). During the surgical procedure, we did not fill the cushion to prevent postoperative urethral injuries when performing CIC in the early postoperative time. At a 12-month follow-up, we had a significant reduction in postoperative 24-hour pad test (median value: 7.5 g; IQR: 0-16.25; P < .05). All patients reached continence. We had a significant reduction in the Qualiveen scores (P < .05). Patients demonstrated to be satisfied with the results of the intervention at the PGI-I questionnaire. The only complications were four cases of temporary scrotal edema (Clavien-Dindo 1) treated with conservative therapy. All patients resumed CIC without urethral traumatism nor catheter insertion difficulties. We had no cases of device infection nor device removal. CONCLUSIONS: Implantation of ATOMS device seems to be an effective and safe minimally invasive procedure also in neurological patients with a low rate of postoperative complications.

L1/2 Intradural Disc Herniation with Compression of the Proximal Cauda Equina Nerves: A Surgical Challenge.

BACKGROUND: Intradural disc herniation (IDH) in the upper lumbar spine is rare. Preoperative radiologic diagnosis can be difficult, making operative planning challenging. We report on a 74-year-old female patient who was diagnosed with an L1-L2 IDH intraoperatively. This case report aims to highlight and discuss the radiological features of IDH and operative challenges when approaching IDH. CASE DESCRIPTION: A 74-year-old female patient presented to outpatient clinic with a 3-month history of significant intermittent neurological claudication and severe lumbar back pain. Her examination was unremarkable apart from a positive left-sided femoral stretch test. Magnetic resonance imaging (MRI) revealed a large central L1/L2 disc herniation causing significant compression of the thecal sac and proximal cauda equina nerve roots. She underwent an elective posterior L1/L2 lumbar exploration. Intraoperatively, identification of the disc was difficult, which led to inadvertent cerebrospinal fluid leak after incision of what was thought to be a disc bulge. Further exploration revealed an intradural disc that was removed via durotomy. The thecal sac was repaired with sutures and TISSEEL (Baxter, Deerfield, Illinois, USA). Postoperatively, the patient complained of weak left lower limb; MRI revealed residual disc remnants causing compression of the cauda equina. She successfully underwent an urgent revision decompression procedure. She was discharged to rehabilitation on postoperative day 14 with weakness in left knee flexion and extension (MRC grade 4/5) and left ankle plantar- and dorsiflexion (MRC grade 2/5). CONCLUSIONS: Upper lumbar IDH represent a surgical challenge. Intraoperative considerations include identification of the disc, intentional or incidental durotomy, intradural discectomy, and anatomical restrictions of operating at the level proximal to the cauda equina.

Patient-Reported Bladder, Bowel, and Sexual Function After Cauda Equina Syndrome Secondary to a Herniated Lumbar Intervertebral Disc.

BACKGROUND: Cauda equina syndrome (CES) is rare neurosurgical emergency requiring emergent surgical decompression to prevent bladder, bowel, and sexual dysfunction that can have significant impact on quality of life. There is a paucity of data relating to the prevalence of these long-term complications. OBJECTIVE: The aim of this observational study was to evaluate the long-term prevalence of CES-related bladder, bowel, and sexual dysfunction and impact on quality of life to inform service provision. METHODS: Participants were selected through coding of operative records of patients who underwent lumbar decompression for CES secondary to a herniated intervertebral disc at two large UK neurosurgical departments between 2011 and 2015 inclusive. A telephone-based survey including both validated and modified tools was used to collect data pertaining to bladder, bowel, and sexual function and impact on quality of life both before development of CES and at the time of the survey, at least 1 year postoperatively. RESULTS: Of 135 patients contacted, 71 (42 male, 29 female) responded. Post-CES compared to pre-CES, there was higher prevalence and significant intrarespondent deterioration of bowel dysfunction, bladder dysfunction, perception of bladder function, sexual function, effect of back pain on sex life, and activities of daily living/quality of life (p < .0001 for all). Significant differences in individual questions pre-CES versus post-CES were also found. CONCLUSION: We show high prevalence of long-term bowel, bladder, and sexual dysfunction post-CES, with functional and psychosocial consequences. Our results demonstrate the need for preoperative information and subsequent screening and long-term multidisciplinary support for these complications.