A Successful Outcome Despite Delayed Intervention for Cauda Equina Syndrome in a Young Patient with a Posterior Epidural Disc Extrusion

Abstract

Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation, this is an unusual presentation with epidural disc extrusion. We present a very rare case of Cauda Equina syndrome, resulting from an epidural disc extrusion at L3-L4 level. Patient care and progress notes were reviewed along with pre-, post-, and intra-operative radiological imaging. Here, a 19-year-old male with a past medical history of type I diabetes mellitus, fell asleep on a chair at home in an unusual position and was unable to walk on awakening. The patient developed progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction. In addition, he experienced paresthesia and severe lower back pain unresponsive to steroids. Pre-operative magnetic resonance imaging (MRI) demonstrated a herniated disk epidurally with disc extrusion and mass effect and compression at the L3-L4 level, wrapping around the posterior aspect of the dura. A diagnosis of cauda equina syndrome was made and surgical decompression was performed. Using microsurgical technique and fluoroscopic guidance, a bilateral laminectomy of L3 was achieved with bilateral partial laminectomy of L4, with bilateral foraminotomy of L4. After removal of the lamina, a mass was immediately visualized in the posterior epidural space. Further dissection of the substance and following it posteriorly, identified the mass as a portion of the extruded disc. Post-operatively, the patient experienced rapid recovery. In conclusion, this case demonstrates that a disc extrusion can occur within the epidural space and can cause cauda equina syndrome. As this presentation is unusual, surgeons must be aware that they may encounter disc mass in unexpected locations, in a clinically delayed setting, long after the initial onset of symptoms.

Cauda Equina Syndrome-Induced Acute Urinary Retention in Patients with Acute Lumbar Disc Herniation: Report of Two Clinical Cases.

“…After the surgery, the patients complained of only incisional pain and he was discharged on postoperative day 3 26 . Douraiswami et al (2016) reported a case of CES caused by disc prolapse.…”

Posterior epidural sequestrated disc presenting with contralateral radiculopathy: a very rare case

“…The first report of "posterior epidural migration of disc" in 1973 by Lombardi [18]. Most patients with posterior epidural sequestrated disc present with bilateral symptoms and different degrees of weakness [2][3][4][5][6][7][8][9][10][11][19][20][21]. Moreover, bowel bladder involvement was not uncommon among patients with posterior epidural sequestrated disc [2-11, 19, 20].…”

“…Mugge L [19] L3-4, 1 Progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction.…”