Hemi-Cauda Equina Syndrome from Herniated Lumbar Disc: a Neurosurgical Emergency?

AbstractBackground: We report experience with patients presenting with a specific combination of symptoms: unilateral sciatica, unilateral sensibility loss in the dermatomes SI to S5 (hemi-saddle) and subjective micturation problems secondary to ruptured lumbar disc. Because of its similarities with a cauda equina syndrome, this combination of symptoms was thought to be a unilateral cauda equina syndrome and it was called hemi-cauda equina syndrome. Consequently, it was treated as an emergency. Methods: Ten patients were evaluated. They compromised 2.3% of all patients undergoing lumbar discectomy. Results: Outcome is good with only 10% persisting minor neurologic deficit (sensibility loss in dermatomes S3 to S5). With the exception of urinary retention or incontinence, duration of symptoms and signs does not seem to influence outcome. Comparing signs, symptoms and radiographic findings with those of a cauda equina syndrome which were recently and thoroughly studied, they were found to be more severe in cases of cauda equina syndrome. Especially, the good outcome, (apparently unrelated to the duration of symptoms in cases of hemi-cauda equina syndrome) contrasted with the treatment results of cauda equina syndrome. Conclusions: We defined the hemi-cauda equina syndrome from ruptured disc as a combination of unilateral leg pain, unilateral sensibility loss in dermatomes SI to S5 and sphincter paralysis (proven urinary retention or incontinence). Motor deficit is not necessarily present. Emergency surgery is warranted. Patients presenting with micturation complaints other than urinary retention or incontinence do not suffer from a hemi-cauda equina syndrome.

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Dorsal extrusion of intervertebral disc as a cause of cauda equina syndrome

Medicinski pregled ◽

10.2298/mpns1108419j ◽

2011 ◽

Vol 64 (7-8) ◽

pp. 419-421

Author(s):

Aldin Jusic ◽

Rasim Skomorac ◽

Hakija Beculic

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Intervertebral Disc ◽

Urinary Retention ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Good Recovery ◽

Resonance Imaging ◽

Extradural Space

We have presented a case of rare dorsally sequestrated lumbar disc herniation manifesting as cauda equina syndrome. The patient was admitted to the Neurological Department of Canton Hospital Zenica due to urinary retention and weakness in both lower extremities. Magnetic resonance imaging showed a compressing mass located in the dorsal extradural space at the L2- L3 level. An extruded intervertebral disc was found intraoperatively. The decompression was followed by good recovery.

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Percutaneous Endoscopic Lumbar Discectomy for Treating Cauda Equina Syndrome Due To Lumbar Disc Herniation

10.21203/rs.3.rs-594596/v1 ◽

2021 ◽

Author(s):

Hai-Chao He ◽

Xiao-qiang LV ◽

Yong-Jin Zhang

Keyword(s):

Back Pain ◽

Lumbar Disc Herniation ◽

Disc Herniation ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Lumbar Discectomy ◽

Leg Pain ◽

Endoscopic Lumbar Discectomy

Abstract Background In recent decades, endoscopic techniques to treat lumbar disc herniation (LDH) have gained popularity in clinical practice. However, there is little literature on the use of percutaneous endoscopic lumbar discectomy (PELD) to treat cauda equina syndrome (CES) due to LDH. This study aims to evaluate the feasibility and clinical efficacy of PELD for treating CES caused by disc herniation, and as well as to report some technical strategies. Methods Between October 2012 and April 2018, 15 patients with CES caused by LDH at the early and intermediate stages of Shi’s classification were selected as the subjects of study, and underwent PELD. All patients were followed up for at least two years. The patients’ back pain and leg pain were evaluated using visual analogue scale (VAS) scores and the Oswestry Disability Index (ODI). Patient satisfaction was evaluated using the MacNab outcome scale. Clinical outcomes were measured preoperatively and at 3 days, 3 months, 6 months and the last follow-up. Results The VAS score for back pain, leg pain and ODI score significantly decreased from preoperatively scores of 6.67 ± 1.05, 7.13 ± 1.19 and 62.0 ± 6.85 respectively, to postoperatively cores of 1.80 ± 0.41, 1.47 ± 0.52 and 12.93 ± 1.03 at the last follow-up postoperatively. These postoperative scores were all significantly different compared with preoperative scores (P < 0.01). According to the modified MacNab outcome scale, 86.67% of these patients had excellent and good outcomes at the final follow-up. Complications included one patient with cerebrospinal fluid leakage and one patient who developed recurrent herniation; the latter patient finally achieved satisfactory results after reoperation. Conclusion PELD could be used as an alternative surgical method for the treatment of CES due to LDH in properly selected cases and appropriate patient selection. However, the operator should pay attention to foraminoplasty to enlarge the working space.

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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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Posterior epidural migration of herniated lumbar disc fragment

Journal of Neurosurgery Spine ◽

10.3171/2010.11.spine10142 ◽

2011 ◽

Vol 14 (3) ◽

pp. 313-317 ◽

Cited By ~ 28

Author(s):

Ahmet Sengoz ◽

Kadir Kotil ◽

Erol Tasdemiroglu

Keyword(s):

Surgical Treatment ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Case Series ◽

Rare Condition ◽

Neurological Deficits ◽

Lumbar Region ◽

Duration Of Symptoms ◽

First Choice

Object Posterior epidural migration of a free disc fragment in the lumbar region is a very rare condition that has only been reported in isolated cases to date. Patients with this condition present with radiculopathy or major neurological deficits. Difficulties in diagnosis and the choice and timing of surgical treatment are important in these cases. In this clinical case series, features of cases with posterior epidural migration of free lumbar disc fragments accompanied by cauda equina syndrome are discussed. Methods Eight cases (0.27%) of posterior epidural migration of disc fragments were detected among 2880 patients surgically treated for lumbar disc herniation between 1995 and 2008. Seven of these patients had cauda equina syndrome. The mean duration of symptoms in the 8 cases was 4.2 days (range 1–10 days). The group included 6 men and 2 women, with a mean age of 48 years (range 34–72 years). The sequestered disc fragments were at the L3–4 level in 6 patients (75%) and the L4–5 level in 2 (25%). Magnetic resonance imaging showed tumor-like ring contrast enhancement around sequestered fragments in 5 patients. The patients' motor, sensory, sexual, and urological functions were evaluated postoperatively, and modified Odom criteria and a visual analog scale were used in the assessment of postoperative outcomes. Results A microsurgical approach was used in all cases. Sequestrectomy with minimal hemilaminotomy and removal of the free segments were performed. The patients were followed up for a mean period of 28.5 months. Three patients (37.5%) had excellent results, 3 (37.5%) had good results, 1 patient (12.5%) had fair results, and only 1 patient had poor results according to the Odom criteria. The main factors affecting the long-term outcomes were the presence of cauda equina syndrome and the time period between onset of symptoms and surgery. Conclusions Patients with posterior migration of a disc fragment present with severe neurological deficits such as cauda equina syndrome. Because the radiological images of disc fragments may mimic those of other more common posterior epidural space–occupying lesions, definite diagnosis of posteriorly located disc fragments is difficult. All of these lesions can be completely removed with hemilaminotomy and sequestrectomy, and early surgical treatment is important as a first choice to prevent severe neurological deficits.

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Postoperative urinary retention in patients undergoing elective spinal surgery

Journal of Neurosurgery Spine ◽

10.3171/2016.8.spine151371 ◽

2017 ◽

Vol 26 (2) ◽

pp. 229-234 ◽

Cited By ~ 26

Author(s):

David Altschul ◽

Andrew Kobets ◽

Jonathan Nakhla ◽

Ajit Jada ◽

Rani Nasser ◽

...

Keyword(s):

Risk Factors ◽

Hospital Stay ◽

Urinary Retention ◽

Spine Surgery ◽

Spinal Surgery ◽

Cauda Equina Syndrome ◽

Foley Catheter ◽

Cauda Equina ◽

Leg Pain ◽

Postoperative Urinary Retention

OBJECTIVE Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence. METHODS The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis. RESULTS Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome. CONCLUSIONS Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.

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The role of surgical decompression of Cauda equina in lumbar disc herniation in recovery of bladder function

Medicinski pregled ◽

10.2298/mpns0408327r ◽

2004 ◽

Vol 57 (7-8) ◽

pp. 327-330 ◽

Cited By ~ 11

Author(s):

Danilo Radulovic ◽

Goran Tasic ◽

Milos Jokovic ◽

Igor Nikolic

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Surgical Decompression ◽

Bladder Function ◽

Duration Of Symptoms ◽

Significant Difference

INTRODUCTION Cauda equina syndrome from lumbar disc herniation accounts for up to 2-3% of all disc herniations. The aim of this study was to investigate whether recovery of bladder function after surgery depends on preoperative duration of disease. Patients and methods This retrospective study included 47 patients who underwent surgery for cauda equina syndrome due to a herniated disc in the period between 1997 and 2002. Eleven patients were female and 36 male, with a mean age of 43 years (range 23-67). All presented with sciatica and saddle hypoesthesia, whereas 13 presented with motor weakness of legs. All patients had been catheterized at the time of admission to the Neurosurgical unit. Levels of herniation were L4-L5 in 27 (57%), L5-S1 in 14 (30%), and L3-L4 in 6 (13%) patients. In 7 (15%) patients, surgery was performed within 48 hours of the cauda equina syndrome onset. None underwent surgery within 24 hours. 13 (28%) patients were operated between the 2nd and 7th day and 27 (57%) after 7th day of the cauda equina onset. The role of preoperative duration of symptoms in recovery of bladder function was examined (chi 2 analysis). RESULTS The follow-up ranged from 15 to 74 months (mean 24.2 months). In 33 patients (70%) excellent result were achieved, in 9 (19%) patients good results and 5 (11%) patients presented with poor results. There was no statistically significant difference concerning the time between the onset of symptoms and surgical decompression and subsequent recovery of bladder function (p>0.05). CONCLUSION After accurate diagnosis and adequate operative treatment, postoperative results of cauda equina syndrome due to lumbar disc herniation appear satisfactory regardless of the timing of surgery.

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Sexual and Bladder Dysfunction in Cauda Equina Syndrome: Correlation with Clinical and Urodynamic Studies

Asian Spine Journal ◽

10.31616/asj.2019.0305 ◽

2020 ◽

Vol 14 (6) ◽

pp. 782-789

Author(s):

Gururaj Sangondimath ◽

Abhinandan Reddy Mallepally ◽

Amrithlal Mascharenhas ◽

Harvinder Singh Chhabra

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Cauda Equina Syndrome ◽

Bladder Dysfunction ◽

Lumbar Disc ◽

Cauda Equina ◽

Bladder Function ◽

Leg Pain ◽

Motor Weakness ◽

Urodynamic Studies

Study Design: Retrospective cohort study.Purpose: To analyze the clinical and sphincteric outcomes and the extent of sexual dysfunction (SD) in subjects with cauda equina syndrome (CES) and to assess their correlation with patient-reported and clinical/urodynamic parameters.Overview of Literature: Despite vast literature present for CES, extent of the problem of SD in CES patients has not received enough attention as reflected by the limited information in literature. Little is known about exact prevalence at presentation or about the recovery. A better understanding of SD and bladder dysfunction in CES secondary to lumbar disc herniation is essential as it commonly occurs in the sexually active age group.Methods: All cases of cauda equine syndrome secondary to lumbar disc herniation were recruited. Biographical and clinical data, history, examination findings, operative variables, recovery, and SD were noted. Water cystometry and uroflowmetry were done pre- and postoperatively. The International Index of Erectile Function questionnaire and Female Sexual Function Index were used to assess SD among the men and women, respectively.Results: A total of 43 patients with up to 2.94-year follow-up were included. Urodynamic studies were found to correlate significantly with age, days of bladder involvement, perianal numbness, and motor weakness (p<0.01). In step-wise regression analysis, perianal sensation and overall motor weakness were bladder function determinants. Bladder function recovery was directly related to the number of delay days (t=2.30, p<0.05) and with unilateral leg pain (t=2.15, p<0.05). Significant correlation between SD with age and days of bladder involvement before surgery was found (p<0.01).Conclusions: Surgery timing is related to patient’s functional and sexual outcomes. Patients with unilateral leg pain and hypocontractile bladder have better outcomes. SD is a remarkable problem in CES.

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Posterior epidural migration of sequestered lumbar disc fragments

Journal of Neurosurgery Spine ◽

10.3171/spi.1999.90.2.0264 ◽

1999 ◽

Vol 90 (2) ◽

pp. 264-266 ◽

Cited By ~ 7

Author(s):

Pierre Robe ◽

Didier Martin ◽

Jacques Lenelle ◽

Achille Stevenaert

Keyword(s):

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Contrast Material ◽

Cauda Equina ◽

Radicular Pain ◽

Content Type ◽

Diagnostic Pitfalls ◽

Fine Print

✓ The posterior epidural migration of sequestered lumbar disc fragments is an uncommon event. The authors report two such cases in which patients presented with either intense radicular pain or cauda equina syndrome. The radiological characteristics were the posterior epidural location and the ring enhancement of the mass after injection of contrast material. The major diagnostic pitfalls are discussed.

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Outcome of Delayed Decompression Surgery for Cauda Equina Syndrome secondary to Lumbar Disc Herniation: A Case Report

IIUM Medical Journal Malaysia ◽

10.31436/imjm.v18i2.88 ◽

2020 ◽

Vol 18 (2) ◽

Author(s):

Lim SM ◽

Johari J ◽

Yusof MI

Keyword(s):

Lumbar Disc Herniation ◽

Disc Herniation ◽

Cauda Equina Syndrome ◽

Lumbar Disc ◽

Cauda Equina ◽

Bowel Dysfunction ◽

Decompression Surgery ◽

Motor Weakness ◽

Post Surgery ◽

Maximum Improvement

Cauda equina syndrome (CES) is a constellation of symptoms which consist of low back pain, sciatica, saddlearea paraesthesia, urinary or faecal incontinence, with or without motor weakness, and sensory deficit. Surgical decompression is indicated as soon as possible, as decompression within 48 hours from onset allows maximum improvement of symptoms. Recovery usually occurs months or years postoperatively. We report a case of a patient with cauda equina syndrome secondary to massive lumbar disc herniation who had undergone urgent decompression one week after onset of urinary and bowel dysfunction. The clinical outcome post surgery was also discussed.

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