Abstract
Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation, this is an unusual presentation with epidural disc extrusion. We present a very rare case of Cauda Equina syndrome, resulting from an epidural disc extrusion at L3-L4 level. Patient care and progress notes were reviewed along with pre-, post-, and intra-operative radiological imaging. Here, a 19-year-old male with a past medical history of type I diabetes mellitus, fell asleep on a chair at home in an unusual position and was unable to walk on awakening. The patient developed progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction. In addition, he experienced paresthesia and severe lower back pain unresponsive to steroids. Pre-operative magnetic resonance imaging (MRI) demonstrated a herniated disk epidurally with disc extrusion and mass effect and compression at the L3-L4 level, wrapping around the posterior aspect of the dura. A diagnosis of cauda equina syndrome was made and surgical decompression was performed. Using microsurgical technique and fluoroscopic guidance, a bilateral laminectomy of L3 was achieved with bilateral partial laminectomy of L4, with bilateral foraminotomy of L4. After removal of the lamina, a mass was immediately visualized in the posterior epidural space. Further dissection of the substance and following it posteriorly, identified the mass as a portion of the extruded disc. Post-operatively, the patient experienced rapid recovery. In conclusion, this case demonstrates that a disc extrusion can occur within the epidural space and can cause cauda equina syndrome. As this presentation is unusual, surgeons must be aware that they may encounter disc mass in unexpected locations, in a clinically delayed setting, long after the initial onset of symptoms.
Highlights
Cauda equina syndrome (CES) is an uncommon, yet serious neurological condition, often best treated with immediate surgical intervention
Surgical intervention for CES caused by disc herniation includes lumbar laminectomy and discectomy in order to relieve spinal cord compression and reestablished
A report by Sengoz et al of an epidural lumbar disc fragment migration suggests that radiological appearance is not specific enough to rule out alternative diagnoses and urgent surgical intervention is necessary to avoid the development of permanent neurological deficits [3]
Summary
Cauda equina syndrome (CES) is an uncommon, yet serious neurological condition, often best treated with immediate surgical intervention. Surgical intervention for CES caused by disc herniation includes lumbar laminectomy and discectomy in order to relieve spinal cord compression and reestablished. A report by Derincek et al demonstrates that migrated lumbar disc can appear as an abscess and tumors and other causes of CES must be considered in the differential when this condition is encountered [1]. A report by Sengoz et al of an epidural lumbar disc fragment migration suggests that radiological appearance is not specific enough to rule out alternative diagnoses and urgent surgical intervention is necessary to avoid the development of permanent neurological deficits [3]. While the constellation of symptoms, which represent CES, are classic and reproducible, the attributable cause may not be clear and imaging may not provide satisfactory insight into the origin
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