Cauda Equina Syndrome Due To Dural Sac Shift with Engorgement of the Epidural Venous Plexus: Rare Complication After Lumbar Microdiscectomy

Abstract BACKGROUND AND IMPORTANCE Endovascular therapy has proven to be a safe, minimally invasive treatment for multiple etiologies, but proper precautions must be taken to avoid complications. When complications occur, they should be promptly identified and corrected when possible. This case report describes endovascular stents misplaced into the epidural spinous venous plexus rather than the iliofemoral arteries, causing cauda equina syndrome, as well as the spinal procedure performed to treat the resulting spinal canal compression. CLINICAL PRESENTATION A 67-yr-old man had undergone what he thought was iliofemoral arterial stenting at an outside hospital for peripheral vascular disease. He presented 8 d later to our hospital with cauda equina syndrome comprising back pain, right L5 radiculopathy, perianal numbness, urinary retention, and constipation. Scans demonstrated stents deployed into the venous system, traversing the spinal canal and the right L5-S1 neural foramen, resulting in severe spinal canal stenosis, right L5-S1 foraminal stenosis, and moderate left S1-S2 foraminal stenosis. The patient underwent an L5-S1 laminectomy with full right L5-S1 facetectomy and left S1-S2 medial facetectomy, with associated L5-S1 posterolateral fusion with fixation to remove the stent and decompress the neural elements. CONCLUSION Although stent misplacement is an uncommon complication of endovascular therapy, this case demonstrates the importance of ensuring access to the proper vessel before stent placement. Once this complication was recognized, safe removal of the stents was possible and the patient demonstrated meaningful postoperative improvement in symptoms and strength.

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Cauda equina syndrome caused by a migrated bullet in dural sac

Turkish Neurosurgery ◽

10.5137/1019-5149.jtn.2247-09.1 ◽

2009 ◽

Author(s):

Wan Jun ◽

Kang Yi-jun ◽

Zhang Xiang-sheng ◽

Wan Jing

Keyword(s):

Cauda Equina Syndrome ◽

Cauda Equina ◽

Dural Sac

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GELFOAM INDUCED CAUDA EQUINA SYNDROME: A CASE REPORT WITH REVIEW OF LITERATURE

10.36106/gjra/0901517 ◽

2020 ◽

pp. 1-3

Author(s):

Nazim Mughal ◽

Deepankar Mishra ◽

Ajay Srivastava ◽

Nikhat Naaz

Keyword(s):

Spinal Surgery ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Neurological Complications ◽

Lumbar Discectomy ◽

Lower Limbs ◽

Gelatin Sponge ◽

Review Of Literature ◽

Hemostatic Agents ◽

Dural Sac

Gelatin sponge (Gelfoam) is quite often used for haemostasis during spine surgery. However due to its property of osmotic expansion after coming in contact with blood, it has the potential to cause serious complications as a result of compression of nearby vital neurological tissues. We report a case of cauda equina syndrome due to retained Gelfoam during spinal surgery. A 35 year old female patient presented with complaints of pain and numbness in lower limbs for 5 months. MRI was suggestive of disc herniation at L4/L5. Lumbar discectomy was done and gelfoam was used for haemostasis. However, patient developed post-operative neurological complications suggestive of cauda equina syndrome. MRI showed gelfoam induced compression of dural sac. Gelfoam removal was done after which marked improvement in symptoms was observed. Conclusion: Hemostatic agents like Gelfoam which are often used during surgeries have the potential to cause compression of vital structures. Therefore, these should be removed once haemostatic control is accomplished and if it is to be retained, prompt post operatively monitoring is essential.

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Dural ectasia and cauda equina syndrome: A rare complication of long-standing fusion

Asian Journal of Neurosurgery ◽

10.4103/ajns.ajns_113_16 ◽

2018 ◽

Vol 13 (2) ◽

pp. 465 ◽

Cited By ~ 1

Author(s):

SumeetG Dua ◽

VrushaliD Bachhav ◽

MiralD Jhaveri

Keyword(s):

Cauda Equina Syndrome ◽

Rare Complication ◽

Cauda Equina ◽

Dural Ectasia

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Symptomatic pneumorachis associated with incidental durotomy during microscopic lumbar disc surgery

Journal of Neurosurgery Spine ◽

10.3171/spi.2006.5.2.165 ◽

2006 ◽

Vol 5 (2) ◽

pp. 165-167 ◽

Cited By ~ 18

Author(s):

Aristedis Rovlias ◽

Emmanuel Pavlakis ◽

Serafim Kotsou

Keyword(s):

Rare Complication ◽

Lumbar Disc ◽

Cauda Equina ◽

Valve Mechanism ◽

Reconstruction Process ◽

Lumbar Microdiscectomy ◽

First Case ◽

Incidental Durotomy ◽

Tomography Scan

✓ Unintended incidental durotomy is not a rare complication of lumbar microsurgery and is usually recognized and treated immediately. The reconstruction process can be complicated further by unpredictable factors. To their knowledge, the authors report the first case of a symptomatic pneumorachis associated with the accidental awakening of a patient during reconstruction of an incidental durotomy following lumbar microdiscectomy. Incomplete cauda equina syndrome developed in the patient on awakening from surgery after reconstruction of an unintended incidental dural tear that occurred during lumbar microdiscectomy. Symptomatic pneumorachis was revealed on an emergency computed tomography scan, and the patient underwent immediate repeated operation to remove air and decompress the spinal canal. The increasing number and complexity of surgical procedures in the lumbar spine contribute to the growing incidence of unintended durotomy. The surgeon should be aware of rare complications that may arise. Development of a vacuum phenomenon in conjunction with a ball–valve mechanism may lead to pneumorachis during durotomy repair. If this rare complication is promptly recognized and confronted, the outcome will not be associated with long-term sequelae.

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Lumbar Arthroplasty Core Herniation Presenting With Cauda Equina Syndrome: Case Report of a Rare Complication

Operative Neurosurgery ◽

10.1093/ons/opy152 ◽

2018 ◽

Vol 16 (5) ◽

pp. 614-618

Author(s):

Clay M Elswick ◽

Hazem M Ahmed

Keyword(s):

Cauda Equina Syndrome ◽

Rare Complication ◽

Lumbar Disc ◽

Cauda Equina ◽

Preoperative Imaging ◽

Unusual Complication ◽

Artificial Disc ◽

Radiographic Findings ◽

Multiple Imaging ◽

Work Up

Abstract BACKGROUND Treatment failures of artificial disc implantation are well-described, but posterior herniation of the arthroplasty core is rare. We present a case of posterior herniation of the arthroplasty core resulting in cauda equina syndrome in a 36-yr-old woman. Preoperative imaging studies including computed tomography (CT), magnetic resonance imaging (MRI), and CT Myelogram were performed; only the CT Myelogram demonstrated the severe compression well. This report highlights the radiographic findings on multiple imaging modalities, clinical implications, and management considerations of posterior arthroplasty failures. OBJECTIVE To demonstrate a rare complication of lumbar arthroplasties. The biomechanical considerations, surgical management, and thorough radiographic work-up demonstrate successful diagnosis and treatment of this unusual complication. METHODS The patient's chart was reviewed for medical history, laboratory and radiographic studies, and outpatient clinical follow-up. RESULTS After imaging work-up, this patient was found to have a herniation of the arthroplasty core at L5-S1. She was taken emergently to the operating room for a decompression at L5-S1 and arthroplasty core removal. She made some recovery neurological, but over 3 mo time, she developed a spondylolisthesis with new back pain and radiculopathy. This ultimately responded well to an L5-S1 instrumented posterior fusion. CONCLUSION Posterior herniation of the lumbar arthroplasty core is a rare complication from implantation of an artificial lumbar disc. Confirmation of the diagnosis is best confirmed with a CT Myelogram. Furthermore, this case underscores the biomechanical importance of the artificial disc given the development of the spondylolisthesis after removal, and fusion after arthroplasty core removal should be considered.

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Postoperative cauda equina syndrome in patients undergoing single-level lumbar microdiscectomy

Neurosurgical FOCUS ◽

10.3171/foc.2005.19.2.12 ◽

2005 ◽

Vol 19 (2) ◽

pp. 1-5 ◽

Cited By ~ 6

Author(s):

Vassilios Dimopoulos ◽

Kostas N. Fountas ◽

Theofilos G. Machinis ◽

Carlos Feltes ◽

Induk Chung ◽

...

Keyword(s):

Cauda Equina Syndrome ◽

De Novo ◽

Cauda Equina ◽

Conus Medullaris ◽

Clinical Findings ◽

Magnetic Resonance Images ◽

Single Level ◽

Lumbar Microdiscectomy ◽

First Case ◽

Intraoperative Electrophysiological Monitoring

Cauda equina syndrome is a well-documented complication of uneventful lumbar microdiscectomy. In the vast majority of cases, no radiological explanation can be obtained. In this paper, the authors report two cases of postoperative cauda equina syndrome in patients undergoing single-level de novo lumbar microdiscectomy in which intraoperative electrophysiological monitoring was used. In both patients, the amplitudes of cortical and subcortical intraoperative somatosensory evoked potentials (SSEPs) abruptly decreased during discectomy and foraminotomy. In the first patient, a slow, partial improvement of SSEPs was observed before the end of the operation, whereas no improvement was observed in the second patient. In the first case, clinical findings consistent with cauda equina syndrome were seen immediately postoperatively, whereas in the second one the symptoms developed within 1.5 hours after the procedure. Postoperative magnetic resonance images obtained in both patients, and a lumbar myelogram obtained in the second one revealed no signs of conus medullaris or nerve root compression. Both patients showed marked improvement after an intense course of rehabilitation. The authors' findings support the proposition that intraoperative SSEP monitoring may be useful in predicting the development of cauda equina syndrome in patients undergoing lumbar microdiscectomy. Nevertheless, further prospective clinical studies are necessary for validation of these findings.

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Cauda equina syndrome: A rare complication in intensive care

Indian Journal of Orthopaedics ◽

10.4103/0019-5413.50873 ◽

2009 ◽

Vol 43 (3) ◽

pp. 309 ◽

Cited By ~ 1

Author(s):

Yogendrasinh Jagatsinh

Keyword(s):

Intensive Care ◽

Cauda Equina Syndrome ◽

Rare Complication ◽

Cauda Equina

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Interventionist performs a “sham” lumbar microdiscectomy: Should interventionalists be performing spinal surgery?

Surgical Neurology International ◽

10.25259/sni_672_2020 ◽

2020 ◽

Vol 11 ◽

pp. 467

Author(s):

Ramsis F. Ghaly ◽

Zinaida Perciuleac ◽

Kenneth D. Candido ◽

Nebojsa Nick Knezevic

Keyword(s):

Spinal Surgery ◽

Cauda Equina Syndrome ◽

Cauda Equina ◽

Sham Operation ◽

Resonance Imaging ◽

Specific Training ◽

Epidural Steroid Injections ◽

Lumbar Microdiscectomy ◽

Interventional Pain Management ◽

Epidural Steroid

Background: Neurosurgeons and orthopedists, who have received specific training, should be the ones performing spinal surgery. Here, we present a case in which spinal surgeons secondarily (e.g., 6 months later) found that a patient’s first lumbar discectomy, performed by an interventional specialist, had been a “sham” procedure. Case Description: A 30-year-old male presented with sciatica attributed to a magnetic resonance imaging documented large, extruded disc at the L4-5 level. An interventional pain management specialist (IPMS) performed two epidural steroid injections; these resulted in an exacerbation of his pain. The IPMS then advised the patient that he was a surgeon and performed an “interventional” microdiscectomy. Secondarily, 6 months later, when the patient presented to a spinal neurosurgeon with a progressive cauda equina syndrome, the patient underwent a bilateral laminoforaminotomy and L4-L5 microdiscectomy. Of interest, at surgery, there was no evidence of scarring from the IPMS’ prior “microdiscectomy;” it had been a “sham” operation. Following the second surgery, the patient’s cauda equina syndrome resolved. Conclusion: IMPS, who are not trained as spinal surgeons should not be performing spinal surgery/ microdiscectomy.

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