Abstract
Background: Typical cauda equina syndrome (CES) presents as low back pain, bilateral leg pain with motor and sensory deficits, genitourinary dysfunction, saddle anesthesia and fecal incontinence. In addition, it is a neurosurgical emergency, which is essential to diagnose as soon as possible, and needs prompt intervention. However, unilateral CES is rare. Here, we report a unique case of a patient who had unilateral symptoms of CES due to cancer metastasis and was diagnosed through electromyography. Methods: A 71-year-old man with diffuse large B cell lymphoma (DLBCL) suffered from severe pain, motor weakness in the right lower limb and urinary incontinence, and hemi-saddle anesthesia. It was easy to be confused with lumbar radiculopathy due to the unilateral symptoms. Lumbar spine magnetic resonance imaging (MRI) showed suspected multifocal bone metastasis in the TL spine, including T11-L5, the bilateral sacrum and iliac bones, and suspected epidural metastasis at L4/5, L5/S1 and the sacrum. PET CT conducted after the third R-CHOP showed residual hypermetabolic lesions in L5, the sacrum, and the right presacral area. Results: Nerve conduction studies (NCS) revealed peripheral neuropathy in both hands and feet. Electromyography (EMG) presented abnormal results indicating development of muscle membrane instability following neural injury, not only on the right symptomatic side, but also on the other side which was considered intact. Overall, he was diagnosed with cauda equina syndrome caused by DLBCL metastasis, and referred to neurosurgical department. Conclusions: Early diagnosis of unilateral CES may go unnoticed due to its unilateral symptoms. Failure to perform the intervention at the proper time can impede recovery and leave permanent complications. Therefore, physicians need to know not only the typical CES, but also the clinical features of atypical CES when encountering a patient, and further evaluation such as electrodiagnostic study or lumbar spine MRI have to be considered.
Highlights
Cauda equina syndrome (CES) refers to a constellation of signs and symptoms that result from damage to the cauda equina, which refers to the portion of the nervous system below the conus medullaris and consists of peripheral nerves, both motor and sensory, within the spinal canal and thecal sac [1]
Weakness of the right leg and ankle developed. He was diagnosed with hypertension, benign prostate hyperplasia (BPH), and diffuse large B cell lymphoma (DLBCL) through neck lymph node biopsy
In the case of unilateral cauda equina, the fact that it is unilateral is easy to confuse with unilateral radiculopathy, and in particular, if there is an underlying urogenital disease such as BPH, it is more likely to be masked, so it is necessary to be careful in treating patients like our case
Summary
Cauda equina syndrome (CES) refers to a constellation of signs and symptoms that result from damage to the cauda equina, which refers to the portion of the nervous system below the conus medullaris and consists of peripheral nerves, both motor and sensory, within the spinal canal and thecal sac [1]. Unlike typical CES, some patients have those symptoms in only the unilateral side, unilateral sensibility loss, weakness, and hemi-saddle anesthesia. It was defined as hemi-cauda equina syndrome and was treated as a neurosurgical emergency, like CES [4]. Unilateral cauda equina syndrome, which requires emergency surgical treatment, can be mistaken for simple unilateral radiculopathy due to its unilateral symptoms. Through this case, which was successful in diagnosis through electromyography (EMG), we report to enable appropriate early treatment without missing the critical time that can leave lifelong sequelae due to late diagnosis or misdiagnosis
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