Acute postoperative cauda equina syndrome following an elective gynecological procedure

Conor B Garry; Woojin Cho; Alan V Job; Alok D Sharan

doi:10.4103/ISJ.ISJ_94_20

CASE REPORTS

Year : 2022 | Volume : 5 | Issue : 1 | Page : 125-128

Acute postoperative cauda equina syndrome following an elective gynecological procedure

Conor B Garry¹, Woojin Cho¹, Alan V Job², Alok D Sharan¹
¹ Department of Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, United States of America
² Department of Orthopaedic Surgery, Northwell Health North Shore/Long Island Jewish Medical Center, Queens, New York, United States of America

Date of Submission	24-Dec-2020
Date of Decision	27-Apr-2021
Date of Acceptance	10-Jun-2021
Date of Web Publication	02-Feb-2022

Correspondence Address:
Conor B Garry
809 Colonial Ave, Norfolk, VA 23507.
United States of America

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ISJ.ISJ_94_20

Abstract

We report a patient with cauda equina syndrome who presented immediately following hysterectomy. Intraoperative cauda equina syndrome is very rare, and to our knowledge, this is the first case reported following a gynecological procedure, which was unequivocally caused by a herniated intervertebral disc. A 72-year-old woman with a history of chronic low back pain and degenerative disc disease was referred to the orthopedic service after developing urinary retention, decreased rectal tone, and diminished bilateral lower extremity sensory and motor function following hysterectomy for the management of endometrial carcinoma. Magnetic resonance imaging revealed a large central disc herniation at L2/3. Due to a delay in recognition of the progressive neurological deterioration that began immediately postoperatively, decompressive surgery was performed between 48 and 72 hours after the onset of symptoms. Emergent surgical decompression including laminectomy and microdiscectomy resulted in improved bowel and urinary function but no improvement in lower extremity strength or sensation. Cauda equina syndrome is a rare but devastating condition whose recognition and management requires vigilance, communication, and early surgical involvement. This case presents novel information that cauda equina syndrome can occur immediately postoperatively from disc prolapse during unrelated procedures.

Keywords: Cauda equina syndrome, decompression, intervertebral disc displacement, postoperative complications

How to cite this article:
Garry CB, Cho W, Job AV, Sharan AD. Acute postoperative cauda equina syndrome following an elective gynecological procedure. Indian Spine J 2022;5:125-8

How to cite this URL:
Garry CB, Cho W, Job AV, Sharan AD. Acute postoperative cauda equina syndrome following an elective gynecological procedure. Indian Spine J [serial online] 2022 [cited 2022 May 25];5:125-8. Available from: https://www.isjonline.com/text.asp?2022/5/1/125/337150

Introduction

Cauda equina syndrome (CES) is a condition marked by a loss of control of bowel or bladder function, sexual dysfunction, and paraplegia caused by injury to or compression of the nerve roots of the spinal cord below the level of the conus medullaris, where they are particularly vulnerable to ischemic insult.^[1],[2] The most common presentation of CES is compression of the intrathecal nerve roots caused by disc herniations at the L4-S1 levels.^[1] CES is a surgical emergency whose successful treatment requires rapid recognition and management. This case report describes the acute postoperative CES of a 72-year-old woman who underwent an elective gynecological procedure without spinal or epidural anesthesia for the management of metastatic endometrial adenocarcinoma.

Case Report

A 72-year-old woman was admitted to the gynecological oncology service for elective surgery to address her stage four endometrial adenocarcinoma. Her history was significant for type two diabetes, anemia, hypertension, and chronic lower back pain. She was diagnosed earlier with grade one anterolisthesis of L3 on L4 and marked disc space narrowing at L4-5 and L5-S1 following several episodes of back pain in the months leading up to surgery, including following diagnostic hysteroscopy two months prior to surgery [Figure 1]. She noted transient bilateral lower extremity radiculopathy following this 86-min hysteroscopy.

Figure 1: Preoperative PA and lateral lumbar spine films

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She underwent exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Extra time was required to manage hepatic, omental, mesenteric, and diaphragmatic metastases. Prior to intubation and lithotomy positioning, the patient complained of acute back pain. Anesthesia time was over seven hours. She received general anesthesia without spinal or epidural component. She demonstrated subjective and objective lower extremity weakness on emergence from anesthesia.

On postoperative day (POD) one, the patient reported back pain, lower extremity weakness, and numbness. On POD two, physiotherapist noted 0/5 strength and diminished lower extremity sensation. She failed her initial catheter trial. On POD three, she failed a second catheter trial. The rectal examination revealed a negligible tone. Neurology opinion suggested CES, possibly caused by a herniated disc or lumbar pathological fracture, although no skeletal tumor metastases were seen on x-rays taken two months prior to surgery [Figure 1]. Following institutional protocol, the neurologist ordered a lumbar spine Magnetic Resonance Imaging (MRI), which revealed a 1.3-cm disc bulge compressing the thecal sac [Figure 2], [Figure 3].

Figure 2: Preoperative midsagittal T2-weighted MRI lumbar spine

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Figure 3: Preoperative axial T2-weighted MRI of lumbar spine showing obliteration of spinal canal

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The orthopedic spine surgeon recommended immediate decompressive surgery. The patient underwent L2 laminectomy and microdiscectomy. Following exposure, a large disc herniation was noted, compressing the thecal sac with cephalad propagation. This was carefully resected and the spinal cord and nerve roots were confirmed to be decompressed.

Postoperative neural examination demonstrated no improvement. She made no significant recovery of function during her admission. She continued to experience proximal lower extremity weakness as well as loss of all meaningful motor control and sensation below her knees throughout follow-up. One year postoperatively, she recovered bladder function, but her lower extremity strength and sensation did not meaningfully improve. She died five years after the procedure without further improvement.

Discussion

CES is a well-documented, though infrequent, surgical complication. Spinal and epidural anesthesia is often implicated, through direct trauma,^[3] exacerbation of perineural cyst disease,^[4] or spinal epidural hematoma formation,^[5] permanent paralysis following epidural blood patch placement has been reported.^[6] Spine surgery, particularly lumbar decompression procedures,^{[7],[8],[9],[10],[11]} is the most commonly reported surgical cause of CES. Spontaneous CES in patients without prior neurological symptoms or direct trauma has also been documented.^[12] However, postoperative CES is seldom described following obstetrical and gynecological procedures^[13],[14] and is not a common neurological risk in this field.^[15]

Avery, et al.^[13] described an 80-year-old woman admitted for vaginal reconstructive surgery under combined spinal and epidural anesthesia who developed acute postoperative CES. Postoperatively, she reported abrupt bowel and bladder dysfunction as well as loss of bilateral lower extremity strength. MRI was unremarkable. She underwent re-exploration of her surgical incision at her family’s insistence without acute findings. After three weeks motor, bowel, and bladder functions normalized.^[13]

Chow, et al.^[14] reported a case of a 31-year-old woman who developed CES following cesarean section. She had a history of low back pain and a recent MRI demonstrating a small L5/S1 paracentral disc bulge. At 36-week gestation, she presented with right-sided L4-S1 motor weakness, bilateral S1 paresthesias, buttock pain, and urge incontinence. She underwent an early cesarean section under combined spinal and epidural anesthesia. Thirty-six hours postoperatively, she developed fecal incontinence, saddle anesthesia, and absent anal reflex. MRI demonstrated a large disc prolapse migrating caudally from L5/S1, obliterating the canal. She underwent an urgent decompression and recovered motor, urinary, and bowel function after three weeks.

Patient positioning has been implicated. Choudhari, et al.^[16] reported a 36-year-old woman with suspected CES following vaginal hysterectomy in the lithotomy position. Computed Tomography (CT) scan demonstrated an acute L4/5 central disc prolapse. She underwent decompression with full relief. Authors have implicated lithotomy position biomechanics as predisposing to disc herniation. However, no studies demonstrate a statistically significant difference between supine, lithotomy, and exaggerated lithotomy positioning.^[17],[18]

Patients reporting chronic back pain, diabetic neuropathy or other preexisting neurological compromise, sexual dysfunction, fecal or urinary incontinence, or urinary retention may mask the symptoms of CES. Although there is no evidence that CES more commonly afflicts the elderly, this population tends to have more distracting comorbidities. These patients particularly may benefit from a thorough preoperative examination to establish a baseline for postoperative surveillance.^[1]

Conclusion

Acute onset CES is rarely associated with obstetrical or gynecological cases, and case reporting has largely implicated spinal–epidural anesthesia or postoperative epidural hematoma as causal or contributory factors. A very low threshold for obtaining prompt imaging studies must be observed to protect these patients from severe and often permanent injury. There is a near-universal agreement that surgical intervention within 24–48 h of symptom onset maximizes CES outcomes. Therefore, rapid recognition, procurement of imaging, and surgical intervention are critical.^[19],[20]

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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