PROGRESSIVE NEUROLOGIC DEFICIT IN THE OBSTETRIC PATIENT:

IS IT CAUDA EQUINA SYNDROME?

Paul Villalon-Iglesias PA-C, DHSc

Mercer Bucks Orthopedics

March 2011
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Cauda equina syndrome (CES) is extremely rare and occurs in one out of about 10,000

pregnancies while over 50% of women experience low back pain (LBP) during pregnancy. A

gravid patient presents with a complaint of LBP for the past two weeks associated with severe

right lower extremity pain and weakness, as well as progressive numbness for the past five days.

She denies bowel or bladder symptoms. A lumbar magnetic resonance imaging (MRI) shows a

very large disc herniation at L5 S1 with an extruded fragment severely compressing the thecal

sac and the S1 nerve root. At the (three month) postoperative follow up visit, the patient had

delivered vaginally without incident, had a begnin examination and was discharged.
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Table of Contents
Page

INTRODUCTION ....................................................................................................................................... 4

CASE REPORT .......................................................................................................................................... 4

Exam ....................................................................................................................................................... 5

Radiologic Findings .................................................................................................................................. 5

Differential Diagnosis ............................................................................................................................... 5

Plan of Care.............................................................................................................................................. 6

Surgery..................................................................................................................................................... 6

Follow up ................................................................................................................................................. 7

Discussion ................................................................................................................................................ 7

Conclusion ............................................................................................................................................... 9

REFERENCES .......................................................................................................................................... 10
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INTRODUCTION

CES is extremely rare especially in the gravid patient in whom LBP is experienced by as

many as fifty percent women during pregnancy (Brown & Levi, 2001). CES occurs most often

during the fifth and seventh month (LaBan, Rapp, Van Oeyen, Meerschaert, 1995). True CES

presents as a triad of symptoms consisting of lower extremity weakness, altered sensation in the

skin of the buttocks and upper posterior thighs (saddle anesthesia), with dysfunction or paralysis

of the bowel and bladder. Patients often have been dismissed by multiple physicians in their

search for relief before presenting to a subspecialist.

CASE REPORT

Patient was a thirty-three year old woman who presented with a five days history of

weakness and ascending numbness below the right knee. She related a two weeks history of right

sided low back pain that radiated to the right buttock, and associated with severe right lower

extremity (RLE) pain most prominent in the posterolateral aspect of her right calf. She denied

perianal numbness or change in bowel or bladder functions such as incontinence. She denied left

lower extremity involvement as well as trauma. The patient was thirty-two weeks pregnant,

Gravida three, Para two, with an uneventful pregnancy to date. Her past medical history included

hypothyroidism and anxiety treated with Synthroid and Zoloft. She had no history of allergies,

alcohol, smoking or illicit drug use. She had been evaluated twice in the last two weeks and

provided with re-assurance before she presented to the emergency department. She was admitted

to the obstetric service secondary to pain and a stat magnetic resonance imaging (MRI) rather

than xray was ordered by obstetrics An orthopedic consult was ordered. The spine surgeon

happened to be on call.
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EXAM

Upon examination, it was revealed that she walked plantigrade, with her right foot

slightly externally rotated. She was unable to dorsiflex or plantarflex her right foot. She was not

able to heel or toe walk on the right, possessed 0/5 strenght at the right extensor hallucis longus

and 2-3/5 at the right tibialis anterior and gastrocsoleus complex. She complained of pain with

elevation of her right leg over 30 degrees and had very limited sensation to light touch in the

right L5 and S1 dermatomes. Deep tendon reflex was absent at the right ankle. Patient refused a

rectal exam or post-void evaluation.

DIFFERENTIAL DIAGNOSIS

One should consider and rule out “trauma, history of malignancies, inflammatory,

infectious, degenerative conditions, or other compressive processes” (Johnston, 1993). Include

pelvic pain of pregnancy, lumbar sprain strain, sciatica, lumbar disc herniated nucleus pulposus

(HNP) with radiculopathy and CES in the differential.

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RADIOLOGIC FINDINGS

Lumbar MRI demonstrated a very large, right sided, disc herniation at L5 S1 with an

extruded fragment severely compressing the thecal sac and the right S1 nerve root, causing

severe right foraminal stenosis at the level of L5 S1. There were degenerative changes at L4 L5

with disc dessication and no lesions were seen.

PLAN OF CARE

Observation, analgesia, physical therapy, epidural injections were discussed with the patient.

Surgery was recommended due to the profound weakness and severity of pain experienced by

the patient as well as the size of the disc herniation.

SURGERY

The patient received epidural anesthesia at L3-L4 level, with a catheter left in place

during the procedure. A test dose of 1.5cc of lidocaine with epinephrine is injected to ensure

proper placement, Marcaine .5% was given in increments of 5cc three times during the case.

Propofol was used for sedation. 2mg of Astromorh (a long-acting morphine) were given to the

patient prior to removal of the epidural catheter. Fetal monitoring was performed by obstetrics.
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A laminotomy, partial facetectomy, and discectomy at L5S1 with excision of free fragment were

performed at L5-S1. Surgical pathology described the disc as 3.5 centimeters (cm) by 1.4 cm by

0.6 cm fibrocartilaginous tissue as noted in the following picture.

FOLLOW-UP

In the immediate post-operative period, the patient continued to complain of pain in the

right lower leg which abated significantly by the time of discharge. Patient was seen in follow-up

four days later and was able to heel and toe walk on the right, her strength had improved to 3-4/5

at the RLE. She continued to have diminished sensation to the plantar aspect of the right foot

which persisted at the one-month follow up and occasional pain in the right buttock. Physical

therapy was started for strengthening of the RLE. At the three-month mark, the patient had

delivered vaginally uneventfully, and had an entirely begnin exam with 5/5 strength at the RLE

and no neurologic deficits. She was cleared to return to light weightlifting with good technique

and lumbar support but was told to hold off on running until the sixth month. She was

subsequently discharged.
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DISCUSSION

Medical problems of the spine have been reported throughout history. Wei (1973),

reports that the very well preserved corpse of a 2100 year-old woman found in China in 1972

showed evidence of lumbar disc disease. In 1934, Drs Mixter and Barr co-authored a landmark

article in the New England Journal of Medicine on intervertebral disc lesion and sciatica that

changed medical thinking an treatment on this condition (Mixter & Barr, August 2, 1934). Drs

Small, Perron, and Brady wrote in 2005 that 90% of adults will experience LBP of unknown

etiology that resolves spontaneously within one to two month without significant treatment and a

good outcome.

LaBan et al. demonstrated that CES occurs in one out of about 10,000 pregnancies in

their 1983, decade-long review of 48,760 consecutive deliveries, with only five patients

identified with symptomatic lumbar herniated nucleus pulposus. The reader should note that few

patients present with all the classic symptoms of cauda equina (Tay & Chacha, 1979) and

“unilateral sciatica with motor and sensory disturbance” was a more common presentation.

(Kostuik, Harrington, Alexander, Rand & Evans,1986). Kostuik et al. also note that “urinary

dysfunction combined with motor and sensory loss in the presence of a disc lesion indicates a

Cauda equina syndrome”. CES is a feared complication of lumbar disc herniation…that requires

urgent surgical decompression (Busse, Bhandari, Schnittker,Reddy & Dunlop, 2001). O’Laoire,

Crockard, and Thomas noted in 1981 that “early recognition of CES caused by lumbar disc

prolapsed can prevent irreversible sphincter paralysis” and that “the urgency of the diagnosis and

treatment may be compared to that for extradural hematoma in head injury”.

An association between the polypeptide relaxin and low back pain as well as pelvic pain

of pregnancy has been suggested (Russell & Reynolds, 1997; MacLennan, Green, Nicholson, &
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Bath, 1986). Relaxin, which is secreted by the corpus luteum, promotes joint laxity in late

pregnancy. Although many cases of lumbar disc prolapse occur during the first and second

trimesters, the highest relaxin levels were found in the most clinically incapacitated patients

(MacLennan et al, 1986). Ashkan, Casey, Powell & Crockard, (1998) also refer to relaxin as a

possible culprit causing sacroiliac strain but note that other causes are implicated, such as

“increased lumbar lordosis, positional and postural stresses, direct pressure on nerve roots by the

gravid uterus…ischaemia of neural elements due to uterine pressure on aorta and vena cava may

also result both in back pain and in its radiation to the legs”.

Early diagnosis through proper physical exam and radiologic studies is paramount. A

rectal examination should be done to assess for sphincter tone, which may be diminished in 80%

of patients, and to assess for perineum sensation (Small et al., 2005). Catheterization, with a

post-void residual urine greater than 100/200cc, has a specificity and sensitivity of 90% or

greater for CES. Small et al. (2005), recommends a straight leg raise maneuver to assess for

radiculopathy. The literature, to include LaBan et al. (1995), Brown et al (2001), Cunningham,

Leveno, Bloom and Hauth (2009) in their manual Williams Obstetrics, support the use of MRI in

the gravid patient to “confirm the diagnosis and establish the level of disc protusion” Busse et al

(2001).

LaBan et al. (1995) and Brown et al. (2001) demonstrated that “disc surgery during

gestation is a safe method of management”. Surgery is a team effort that should include fetal

monitoring by obstetrics. Spinal or general anesthesia can be achieved safely for both the mother

and the unborn child (Miller, Fleisher, Wiener-Kronish, Young & Eriksson, 2010). There are no

clear evidences to “indict any anesthetics as a teratogen” (Miller et al, 2010, p. 2059). A survey

from several Swedish registries across an eight-year span, examined 5405 operations in a
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population of 720,000 pregnant women. The results found an increased incidence of low-birth

weight and death within 168 hours in first trimester patients (Miller et al, 2010). “Adequate

oxygenation and avoidance of hyperventilation are mandatory” (Miller et al, 2010, p. 2060).

CONCLUSION

“The major pitfall in diagnosis is not including CES in the back pain differential” Small

et al., 2005). Our patient did not have a true presentation of CES but her symptoms warranted a

full workup and treatment which prevented possible long-term sequelae. Medical practitioners

should be familiar with the triad presentation of CES. Practitioners must differentiate LBP of

muscular origin from lumbar disc herniation and have the ability to appreciate the degree of

symptom severity reported by the gravid patient. A thorough history and physical assessment

must be done every time. When in doubt, err on the side of caution, refer for MRI and consult a

specialist.
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REFERENCES

Ashkan, K., Casey, A.T.H., Powell, M., Crockard, H.A. (1998). Back pain during pregnancy and
after childbirth: an unusual cause not to miss. Journal of the Royal Society of Medicine,
91, 88–90.

Brown, M., MD, Levi, A.D. (2001). Surgery for lumbar disc herniation during pregnancy.
Spine, 26, 440 – 3.

Busse, J.W., DC, Bhandari, M., MD, Schnittker, J.B., MD, Reddy, K., MD, Dunlop, R. B., MD
(2001). Delayed presentation of Cauda equina syndrome secondary to lumbar disc
herniation: functional outcomes and health-related quality of life. Canadian Journal of
Emergency Medicine, 3(4), 285-291.

Cunningham, F., Leveno, K., Bloom, S., Hauth, J. (2009). Williams Obstetrics, 23rd edition,
McGraw Hill companies.

Fast, A., Shapiro, D., Ducommun, E.J., Friedmann, L.W., Bouklas, T., Floman, Y. (1987).
Low-back pain in pregnancy. Spine, 12, 368-71.

Johnston, R.A. (1993). The management of acute spinal cord compression. Journal of
Neurology, Neurosurgery, and Psychiatry, 56, 1046-1054.

Kostuik, J.P., Harrington, I., Alexander, D., Rand, W., Evans, D. (1986). Cauda equina
syndrome and lumbar disc herniation . The Journal of Bone and Joint Surgery,68, 386
-391.

LaBan, M.M., Perrin, J.C.S., Latimer, F.R. (1983). Pregnancy and the herniated lumbar disc.
Archives of Physical Medicine and Rehabilitation, 64, 319–321.

LaBan, M.M., Rapp, N.S., Van Oeyen, P., Meerschaert, J.R. (1995). The lumbar herniated disk
of pregnancy: a report of six cases identified by magnetic resonance imaging. Archives of
Physical Medicine and Rehabilitation, 76, 476–9.

MacLennan, A.H, Green, R.C, Nicholson R, Bath M. (1986). Serum Relaxin and Pelvic Pain of
Pregnancy. Lancet, 2 (8501), 243–5.

Miller, R.D., Fleisher, L.A., Wiener-Kronish, J.P., Young, W.L., Eriksson, L.I. (2010). Miller’s
Anesthesia, Philadelphia: Churchill Livingston, Elsevier Health Science.

Mixter, J., MD., Barr, Joseph S., M.D. (August 2, 1934). Rupture of the Intervertebral Disc with
Involvement of the Spinal Canal. New England Journal of Medicine, 211, 210-5.
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REFERENCES (cont.)

O’Laoire, S.A., Crockard, H.A., Thomas, D.G. (1981). Prognosis for sphincter recovery after
operation for cauda equina compression owing to lumbar disc prolapse. British Medical
Journal 282, 1852–4.

Russell, R., Reynolds, F. (12 April 1997). Back pain, pregnancy, and childbirth, British Medical
Journal 314, 1062.

Small, S. A., MD, Perron, A. D., MD, Brady, W. J., MD (March 2005). Orthopedic pitfalls:
Cauda Equina Syndrome. American Journal of Emergency Medicine, 23, (2), 159-163.

Tay, E.C.K., Chacha P.B. (1979). Midline prolapse of a lumbar intervertebral disc
with compression of the cauda equina. Journal of Bone and Joint Surgery 61 B, 43-6.

Wei, O. (1973). Internal Organs of a 2100 Years Old Female Corpse. Lancet, 2, Page 1198.