Loss of Bowel Control in a Field Hockey Player

Abstract

HISTORY: A 19-year-old female college field hockey player presented to the sports medicine clinic at the beginning of the fall semester with progressively worsening low back pain with radiculopathy. She was treated with IM Toradol and started on prednisone, Percocet and ibuprofen. Five days later, while awaiting neurosurgical evaluation, she received an epidural steroid injection that provided significant relief. Three days later she was hospitalized for intractable pain, and subsequently had acute loss of bowel and bladder control. During the previous spring semester she complained of low back pain and vague radicular symptoms. Over the summer she was diagnosed with L5-S1 disc herniation and underwent two epidural steroid injections prior to her return to school in the fall. PHYSICAL EXAMINATION: Appeared significantly uncomfortable. Antalgic gait. Difficulty weight bearing on right leg. Tenderness midline L3-S1, markedly at L5-S1 and into buttocks. Right lumbar paraspinal muscle spasm. Weak right extensor hallicus longus. Absent right ankle jerk. Positive slump test. DIFFERENTIAL DIAGNOSIS: Cauda equina syndrome due to L5-S1 disc herniation Cauda equina syndrome due to iatrogenic causes (epidural steroid injection) Cauda equina syndrome due to spinal stenosis Cauda equina syndrome due to neoplasm TEST AND RESULTS: Lumbar spine radiographs, AP and lateral: L3-S1 scoliosis 10 degrees. MRI lumbar spine: Moderate-sized L5-S1 disc herniation. CT lumbar spine: Bilateral spondylolysis of L5. Grade I spondylolisthesis of L5 on S1; small osteophyte off posterior superior endplate of S1. FINAL WORKING DIAGNOSIS: Cauda equina syndrome secondary to acute L5-S1 disc herniation and spondylolisthesis. TREATMENT AND OUTCOMES: 1. Emergency L5-S1 decompression with laminectomy and reconstruction with posterior interbody fusion at L5-S1 with radiolucent cages, bone morphogenic protein and posterior pedicle screw fixation. 2. Return of normal neurologic function. 3. Five days after discharge had worsening back pain and syncopal episode. Pulmonary embolism idenitified on CT. Treated with enoxaparin. 4. Discharged home on Coumadin, oxycodone, dexamethasone. 5. Returned to classes 1 month post-op. 6. One week later had shortness of breath. CT arteriogram normal, resolution of prior pulmonary embolism.