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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 1  |  Issue : 3  |  Page : 56-58

A very rare case of cauda equina syndrome due to lumbar disc prolapse in a pregnant woman in the second trimester


1 Department of Spine Surgery, Sunshine Hospitals, PG Road, Secunderabad, India
2 Department of Spine Surgery, STAR Hospitals, Banjara Hills, Hyderabad, Telangana, India
3 Department of Spine Surgery, Sunshine Hospitals, PG Road, Secunderabad; Department of Spine Surgery, STAR Hospitals, Banjara Hills, Hyderabad, Telangana, India

Date of Web Publication18-Dec-2017

Correspondence Address:
Dr. G PV Subbaiah
STAR Hospitals, Road No. 10, Banjara Hills, Hyderabad - 500 034, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EJSS.EJSS_13_17

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  Abstract 


Low back pain is a frequently encountered issue in pregnant women affecting >50%; incidence of low back pain secondary to lumbar disc herniation in pregnancies is low (1:10000). Cauda equina syndrome from lumbar disc herniation is a serious complication; delay in diagnosis and treatment can be a cause of chronic disability secondary to neurological sequelae. Numerous cases of disc herniation in pregnancy have been reported; however, cauda equina syndrome as a result of disc herniation is rare (2%). Here we are reporting a rare case of cauda equine syndrome in a pregnant woman at 16-week gestation is presented. We present a rare case of 30-year-old woman (G3P2L0) at 16-week gestation, presented initially at an emergency department at a district level hospital with low backache radiating to both the lower limbs treated with pain medications; 48 h later, the patient presented to us with bilateral foot drop with saddle anesthesia, urinary and fecal incontinence. On physical examination, the patient has bilateral foot drop with complete weakness of extensor hallucis longus and ankle inversion of both feet. The lumbar magnetic 'g (MRI) scan showed massive central disc herniation in L4–L5 level with severe central canal stenosis. After assessment by the anesthesiology and gynecology departments using a posterior approach under prone position, bilateral laminotomy and discectomy was performed at L4-L5 level. No complications were observed in the mother and the fetus during and after the surgery. Pain has subsided immediate post-op, three months after surgery, the patient was walking normally with minimal saddle hypoesthesia. The pregnancy proceeded normally, and she gave birth for full-term baby without any complications delivered by cesarean section. Clinical picture of low back pain is very frequent during pregnancy. However, we should perform an MRI scan for sudden onset of sciatica associated with loss of strength, bowel, and bladder disturbance. Patient diagnosed with cauda equina syndrome should undergo emergency surgery to minimize neurological sequelae.

Keywords: Cauda equina syndrome, disc herniation, pregnant women


How to cite this article:
Penkulinti M, Banala RR, Santosh V, Subbaiah G P. A very rare case of cauda equina syndrome due to lumbar disc prolapse in a pregnant woman in the second trimester. J Spinal Stud Surg 2017;1:56-8

How to cite this URL:
Penkulinti M, Banala RR, Santosh V, Subbaiah G P. A very rare case of cauda equina syndrome due to lumbar disc prolapse in a pregnant woman in the second trimester. J Spinal Stud Surg [serial online] 2017 [cited 2018 Oct 21];1:56-8. Available from: http://www.jsss-journal.com/text.asp?2017/1/3/56/221104




  Introduction Top


Low back pain is a frequently encountered issue in pregnant women due to mechanical and positional overload affecting >50% cases.[1],[2],[3],[4] The incidence cauda equina syndrome secondary to lumbar disc herniation is very rare in pregnant women (i.e., 1:10000).[1],[2] Cauda equina syndrome from lumbar disc herniation is a serious complication, characterized by bilateral leg pain, saddle hypoesthesia lower limb strength, and genitourinary sphincter disturbances, if delayed in diagnosis and treatment, can lead to chronic disability secondary to neurological sequelae.[1] Numerous cases of disc herniation in pregnancy have been reported; however, the association of cauda equina syndrome as a result of disc herniation is rare (2%).[5],[6] A rare case of cauda equina syndrome in a pregnant woman at 16-week gestation is presented. To our knowledge, this is the second case of cauda equina syndrome being reported after Mohapatra and Patra (2008)[2] from India.


  Case Report Top


Here, we present a rare case of 30-year-old woman (G3P2L0) at 16-week gestation, presented initially at an emergency department at a district level hospital with low backache radiating to both the lower limbs treated with pain medications; 48 h later, the patient presented to us with bilateral foot drop with saddle anesthesia urinary and fecal incontinence. On physical examination, the findings were foot drop with complete weakness of extensor hallucis longus and ankle inversion on both sides.

Sensation decreased over L4, L5, and sacral dermatomes bilaterally. The ankle reflex was lost on both sides. The straight leg raising test at 40° was positive for both sides. The lumbar magnetic resonance imaging (MRI) scan showed massive central disc herniation in L4–L5 with severe central canal stenosis [Figure 1].
Figure 1: (a) Sagittal slice magnetic resonance imaging scan showing massive disc herniation in L4–L5 level (b) axial slice magnetic resonance imaging: Massive disc herniation with central canal stenosis.

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  Results Top


After assessment by the anesthesiology and obstetrician departments, as the cauda equina syndrome is a surgical emergency, it was decided to operate on the patient. Risk of post operative fetal distress and fetal death were explained to the patient. Under general anesthesia, the patient was positioned prone with good cushions avoiding abdominal compression; using midline posterior approach, L4-L5 discectomy was performed. The surgery was uneventful as there were no complications observed in the mother and the fetus during and after the surgery. Foetal Doppler and ultrasound scans were done to assess the condition of the fetus pre and post operatively. Pain was subsided immediate post op. Three months after the surgery, the patient was walking normally with minimal saddle hypoesthesia. The pregnancy proceeded normally and she underwent cesarean section due to functional dystocia and gave birth to full-term baby without any complications


  Discussion Top


Low back pain in pregnant women is a common medical issue observed in 50% of cases. The most common functional changes observed in pregnant women are increased weight of the uterus, stretching of adjacent and surrounding tissue leading to postural change, stress on sacral joint, and separation of pubic bones.[1],[2],[3],[4] Due to increased lordosis in the lumbar spine of pregnant women, their abdominal wall muscles get stretched and paraspinal muscles get shortened. Cauda equina syndrome syndrome should be considered as a medical emergency.[2] As a matter of fact, cauda equina syndrome which occurs in pregnant women does not mean for termination of pregnancy, but the surgery can be done with a good outcomes for the mother and the foetus.

The disability because of neurological deficits in the form of motor weakness and sphincter disturbances can be a major risk factor. Proper diagnosis is essential. If there are any sphincter disturbances, a proper rectal examination has to be done for testing the tone of anal sphincter. An emergency MRI can be performed if the anal sphincter is hypotonic.[7],[8] The MRI scans and general anesthesia procedures can be advised and they are relatively safe for mother and fetus.

Numerous studies support the emergency nerve decompression surgery, given that the spinal compression time is considered as a predictive factor. The predicted outcomes can be categorized based on the chances of total recovery, i.e., unilateral sciatica has better chances for recovery than bilateral sciatica and development of vesical sequelae in patients with perineal anaesthesia. The positioning of the patient has to be done with prior care for preventing excessive abdominal compression.[5],[9],[10] In our case, a bilateral laminectomy and discectomy was performed with posterior approach and prone position in the patient; the mother or fetus did not show any complications.[6]


  Conclusion Top


Clinical picture of back pain is very frequent during pregnancy. However, we should perform an MRI scan for sudden onset of sciatica associated with loss of strength, bowel, and bladder disturbance. The patient diagnosed with cauda equina syndrome should undergo emergency surgery within 24–48 h for minimizing neurological sequelae.


  Highlights Top


  1. It is a rare case of cauda equina syndrome
  2. Patient presented with disability at 16 weeks of gestation
  3. Patient delivered a full-term baby with no complications.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We thank our colleagues from Radiology Department for their help in diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Antón Capitán B, Malillos Torán M. The cauda equina syndrome in pregnant woman with a massive disc herniation. Rev Esp Cir Ortop Traumatol 2017;61:63-5.  Back to cited text no. 1
    
2.
Mohapatra RN, Patra RK. Cauda equina syndrome in pregnancy due to disc prolapse. J Indian Acad Clin Med 2008;9:140-2.  Back to cited text no. 2
    
3.
Curtin P, Rice J. Cauda equina syndrome in early pregnancy: A case report. Acta Obstet Gynecol Scand 2007;86:758-9.  Back to cited text no. 3
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4.
Speirs E, Wiles M, Bacon A, Radley S. Positioning a proned patient with cauda equina syndrome who presents at 15 weeks gestation: A case report. F1000Res 2014;3:117.  Back to cited text no. 4
    
5.
Hakan T. Lumbar disk herniation presented with cauda equina syndrome in a pregnant woman. J Neurosci Rural Pract 2012;3:197-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP, et al. Cauda equina syndrome secondary to lumbar disc herniation: A meta-analysis of surgical outcomes. Spine (Phila Pa 1976) 2000;25:1515-22.  Back to cited text no. 6
    
7.
LaBan MM, Rapp NS, von Oeyen P, Meerschaert JR. The lumbar herniated disk of pregnancy: A report of six cases identified by magnetic resonance imaging. Arch Phys Med Rehabil 1995;76:476-9.  Back to cited text no. 7
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8.
Kim HS, Kim SW, Lee SM, Shin H. Endoscopic discectomy for the cauda equina syndrome during third trimester of pregnancy. J Korean Neurosurg Soc 2007;42:419-20.  Back to cited text no. 8
[PUBMED]    
9.
Abou-Shameh MA, Dosani D, Gopal S, McLaren AG. Lumbar discectomy in pregnancy. Int J Gynaecol Obstet 2006;92:167-9.  Back to cited text no. 9
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10.
Gupta P, Gurumurthy M, Gangineni K, Anarabasu A, Keay SD. Acute presentation of cauda equina syndrome in the third trimester of pregnancy. Eur J Obstet Gynecol Reprod Biol 2008;140:279-81.  Back to cited text no. 10
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