PBL

BACK PAIN

DEPARTMENT OF SURGERY
FACULTY OF MEDICINE
5TH YEAR PHASE III PBL

BACK PAIN

Dept. of Surgery

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Case Trigger
A 54-year-old man Indian manual worker
presented to the emergency department for low back
pain and numbness in both lower extremities of one
day duration. One week earlier, he had sharp,
shooting pains in the back and buttocks after moving
boxes. The pain was relieved with pain medications.
However, on the morning of presentation, the patient
awoke with numbness in both lower extremities and
had left leg weakness so severe that the patient was
unable to stand or walk without support. The patient
described the pain as mild while he was supine and
worse when he sat or stood. The patient reported
some urinary hesitancy, dribbling of urine, and
constipation.

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Clinical Data
Approximately 7090% of adults will experience acute low
back pain during their lifetimes. Most cases will resolve
within six weeks. It is estimated that 85% of patients have no
definitive diagnosis and are presumed to have pain
originating from the soft tissues. Red flags include history of
trauma, malignancy, B symptoms, neurological
manifestations (motor and sensory), and sphincteric
dysfunction.
Urgent diagnosis and management are the most important
factors that affect prognosis.

Clinical examination
Vitals: BP 130/85, Heart rate 110 BPM, respiratory rate 12,
temperature 37.5 C.
General exam: healthy looking male not in distress
Cardiovascular, respiratory, and GI systems exam was
normal
The back was not tender when palpated. The straight-legraise test to 30 did not elicit additional pain in other leg.
Motor strength examination showed good motor function in
all muscle groups of the right lower extremity. Motor strength
of the left lower extremity was decreased to 3 out of 5 in the
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hamstrings, iliopsoas, and quadriceps muscles; 1 to 2 out of

5 in the ankle and toe plantar flexor muscles; and 0 out of 5
in the ankle dorsiflexor muscles and extensor hallicus longus
muscle. Tests of the deep tendon reflexes showed normal
right patellar reflex, absent left patellar reflex, and absent
Achilles tendon reflexes bilaterally. Sensory examination
demonstrated hyperalgesia of the left calf and hyposthesia of
the scrotum, perianal area, and left foot. Anal sphincter tone
was reduced

Investigation
1. X-ray of Lumbar spine

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2. Blood work up:

a. CBC:
b. Electrolytes is normal
c. Erythrocyte sedimentation rate
d. C reactive protein is elevated
e. More work up?
3. MRI study

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Dept. of Surgery

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THIS is normal MRI spine (for comparison

purpose)

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Diagnosis:
Cauda Equina Syndrome.

Principle of assessment
Diagnostic dilemmas arise because the condition is rare
and patients can present with vague neurological
compromise and only mild to moderate pain.

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The most consistent exam finding is a measured urinary

retention of more than 100-200 milliliters of post-void
urine volume.

A sensory deficit over the buttocks and upper posterior

thigh and perianal area is found in 75% of cases and
decreased anal sphincter tone is present in 60-80% of
cases.
Lack of evidence on examination does not rule out the
diagnosis and in all cases where there is high clinical
suspicion, an MRI of the lumbar spine should be performed

Management
An urgent intervention for decompression is the most
effective line of treatment.
Surgery usually involve removing the disc and
decompress the spine and stabilize that segment with
posterior fixation
There is no role of medical treatment in cauda equine
syndrome

Discussion
Cauda equina syndrome is most commonly due to
massive central disc herniation, which causes
compression of multiple, bilateral lumbar and sacral
nerve roots. It can also be caused by spinal epidural
abscess, haematoma, trauma and malignancy.

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Red flags include the following:

Age under 18 or over 50 years of age
History of malignancy or unexplained weight loss
Fever or immunocompromise suggesting abscess
or intravenous drug abuse
Progressive neurological deficit, such as bowel or
bladder incontinence or saddle anaesthesia.
Recent trauma (other than strain) or osteoporosis
Three variations of CES have been described: 1) acute
CES that occurs suddenly in patients without previous
low back problems; 2) acute neurologic deficit in
patients who have history of back pain and sciatica; and
3) gradual progression to CES in patients who have
chronic back pain and sciatica. However, in more than
85% of the cases, the signs and symptoms of CES
develop in less than 24 hours
MRI is the widely accepted standard for the rapid and
complete evaluation of a patient with clinically
significant spinal pathology and should be obtained
emergently when the diagnosis of CES is suspected
CES is an absolute indication for emergent surgical
decompression; laminectomy followed by gentle
retraction of the cauda equina (to avoid complications of
increased neurologic compromise) and discectomy is
the technique of choice
Traditionally, patients with CES who have surgery within
24 hours of initial symptoms are believed to have
clinically significantly better neurologic recovery

Conclusions

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Acute compression of the cauda equina is a neurologically

compromising and potentially debilitating syndrome.
Physicians who evaluate low back pain must be able to
recognize the signs and symptoms of this relatively rare but
critical spinal syndrome and must expedite emergent
evaluation with appropriate history and physical examination,
imaging studies, and consultations.
Patients with neurologic deficits of the lower extremities,
perianal region, scrotum, penis, bowel or bladder (or both)
need further evaluation.
Patients with bowel or bladder incontinence should be
considered to have neurologic spinal compromise until
proven otherwise and need emergent imaging studies,
preferably MRI.
If the diagnosis of CES is confirmed, surgical intervention
should be done as soon as possible to prevent progression
of neurologic symptoms and to allow maximum neurologic
recovery.

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