Cauda Equina Syndrome

 

Clinical Key Points

This patient suffered a Cauda Equina Syndrome but despite urgent treatment was left with severe& degrading symptoms said to be untreatable.

History & Prior Treatment

He developed severe back pain in 1979 with symptoms radiating down the posterior aspect of both legs and laying him up in bed for some 4 months. Symptoms improved allowing him to conduct very physical jobs thereafter until he suffered with a Cauda Equina syndrome in 2005 requiring an urgent L4/5 laminectomy and discectomy. However surgery did not take place for 18 hours and has left him with significant neurological deficits. His presenting symptoms were predominantly lower leg pain amongst back, buttock and leg pain. His sitting duration was 5-20 minutes on a hard chair, 20-30 minutes on a soft chair, the static standing duration was less than 5 minutes & a walking duration of 20-30 minutes on even ground & 5-20 minutes on an incline

Distribution of symptoms

His pain manikin revealed stabbing pain at the lumbosacral junction and burning and numbness over the sacrum, coccyx and throughout the perineal region and down the posterior aspect of the left thigh and calf and into the dorsum of the left foot. More severe symptoms occur in the right leg where he had a combination of burning and numbness and lancinating pain down the posterior thigh, calf and into the sole and lateral aspect of the right foot.

Investigations

Weight bearing X-rays revealed the L4/5 disc height was reduced by 60%. The L4/5 facet joints were overriding. The foraminal volume at L5/S1 was very small and there was facet joint hypertrophy at this level as well.

MRI scans revealed a previous L4/5 discectomy with moderate scarring but no definite root compression by the disc. Disc extrusion at L5/S1 compromising the left transiting S1 root.

Sensation in the thighs and shins appeared to be normal but pressure over the right fibula head produced an improvement in the numbness in the dorsum of the right foot.

Both calves were numb. He had numbness in the sole of the right foot whilst the sole of the left foot was hypersensitive. Sensation in the dorsum of the right foot was absent whilst that on the left side was normal. Both ankle jerks were absent and the left knee jerk was absent. Eversion and EHL function on the right was muscle power Grade 3/5 part whilst right plantar flexion power was 4/5.

Endoscopic Minimally Invasive Spinal Surgery: June 2009

Right L4/5 Spinal Probing and Discography and Endoscopic Lumbar Decompression and Foraminoplasty.

Endoscopic Lumbar Decompression and Foraminoplasty revealed extremely widespread granulation tissue throughout the Safe Working Zone, extraforaminal and epidural spaces. A highly sensitised and flattened nerve was noted adherent to the Superior Foraminal Ligament, together with hypervascular injection of the disc wall, vertebral rim osteophytes, hypertrophic facet joint and an apical osteophyte compressing and tethering the nerve.

  • The facet joint was undercut and access gained to the epidural space. The descending and exiting nerves produced pain in the L5 distribution.
  • The Superior Foraminal Ligament was resected. The vertebral rim osteophyte was resected and chamfered until a positive fat sign was achieved. Apical osteophytes were resected. Thus the nerve was liberated.
  • Endoscopic Intradiscal Discectomy was carried out and 0.5 gms of fibrotic disc was removed. A 500Joule 20 watt shrinkage of the disc wall (Annuloplasty) was performed.

Outcome

To date he gets very little pain and this only occurs if he overdoes things. He returned to work after three and a half weeks but regrettably was made redundant But secured a better sales job.

He is back in the swimming pool doing his exercise and he feels that his foot planting has recovered. The incidence of foot inversion has dramatically improved and is now rare. He has had improvement in his testicular sensation and there is a concomitant improvement in bowel function and rectal tone and he is no longer taking laxatives. He has had only two occasions of his sciatic pain and back pain whereas previously this was very frequent.

The burning perirectal pain was previously constant and now only occurs after prolonged sitting. The sensation in the calf and foot has recovered. The pins and needles in the toes passed through a period of itching with gradual recovery of normality and with this a normalisation of shoe wear pattern.