Massive Lumbar Disc Herniation Causing Cauda Equina Syndrome That Presents As Bladder and Bowel Dysfunction in the Absence of Lower Extremity Weakness.

Kimitaka Nakamura,Takahiro Hamada,Ryuta Imamura,Akihiko Inokuchi,Takeshi Arizono

doi:10.7759/cureus.17952

Abstract

The purpose of this report is to examine the features of cauda equina syndrome (CES) presenting as bladder and bowel dysfunction in the absence of lower extremity weakness. Between July 2015 and July 2016, we experienced four cases of massive LDH causing CES that presented as bladder and bowel dysfunction in the absence of lower extremity weakness. Herein, we describe the clinical features of these four patients (two males and two females) who were followed for a minimum of two years postoperatively. The mean age at the time of surgery was 46.8 years (range, 37-71 years). The disc herniation lesion was at the L4/5 level in one patient, and the L5/S1 level in three. The mean interval between the onset of CES and complete surgical decompression was 10.5 days (range, 1-18 days). Postoperative outcomes were better than poor in three of four cases, while one case had residual sphincter dysfunction. LDH causing CES is considered an indication for immediate surgical decompression; however, diagnosis of CES is likely to be delayed in atypical cases of CES that present as bladder and bowel dysfunction in the absence of lower extremity weakness. Diagnosis of CES tended to be delayed in cases without lower extremity weakness. Clinicians should recognize even sensory impairment alone of the dominant area supplied by S2-4 is an important diagnostic sign of CES in the early stage.

Highlights

Cauda equina syndrome (CES) secondary to lumbar disc herniation (LDH) is a relatively uncommon but serious condition that may progress to paralysis and permanent bladder and bowel dysfunction [1,2]; it is considered an absolute indication for surgical decompression [3,4]
We reviewed the clinical data from four patients who underwent surgical decompression for LDH causing CES that presented as bladder and bowel dysfunction in the absence of lower extremity weakness between July 2015 and July 2016
Gleave and McFarlane originally reported the classification of CES following the severity of sphincter dysfunction into two stages: incomplete CES (CESI), which is characterized by reduced sphincter function; and CES in retention (CESR), which is characterized by complete loss of sphincter function [11]

Summary

Introduction

Cauda equina syndrome (CES) secondary to lumbar disc herniation (LDH) is a relatively uncommon but serious condition that may progress to paralysis and permanent bladder and bowel dysfunction [1,2]; it is considered an absolute indication for surgical decompression [3,4]. CES presents with various symptoms, but it is often accompanied by pain in the lower back and the lower extremities, motor weakness, and bladder and bowel dysfunction because of massive disc prolapse [7]. We experienced four cases of massive LDH causing CES in which the patients presented with bladder and bowel dysfunction in the absence of lower extremity weakness. In patients with bladder and bowel dysfunction who do not present with intractable pain and lower extremity weakness, diagnosis of CES may be delayed and the operative outcomes might be poor. The purpose of the present study was to examine the features of CES presenting as bladder and bowel dysfunction in the absence of lower extremity weakness to highlight the features of this rare condition

Objectives

Discussion

Conclusion