Original Research Article Indian Journal of Emergency Medicine Volume 4 Number 4, October - December 2018 DOI: http://dx.doi.org/10.21088/ijem.2395.311X.4418.15 A Case of Delay in Diagnosis of Cauda Equina Syndrome along with Complications; Ideally, a Surgical Emergency Tanmay Kumar Jha1, Sarat Kumar Naidu2, Dheeraj Bhaskaran Nair3 Author’s Affiliation: Abstract 1DNB Resident 2Attending Consultant 3HOD, Dept .of Emergency Medicine, Max Super Cauda equina syndrome is a clinical syndrome characterized by low back Speciality Hospital, Vaishali, pain, unilateral or bilateral sciatica, motor weakness of lower extremities, Ghaziabad, Uttar Pradesh 201012, saddle anesthesia, bowel and bladder dysfunction and occasionally India. paraplegia—resulting fromcauda equina compression. It can be described Corresponding Author: in two forms basedon the onset of signs and symptoms-if symptoms appear Tanmay Kumar Jha, DNB Resident, within 24 hours then it is acute in onset and if patient develops symptoms Dept. of Emergency Medicine, Max after several weeks or months then it is gradual in onset. The sooner it Super Speciality Hospital, Vaishali, can be diagnosed, the better is the chance that the patient makes a better Ghaziabad, Uttar Pradesh 201012, recovery from symptoms of nerve damage. We present a case of a 24-year India. old male with history of fall 6 months back who was treated outside with E-mail: drtanmaykumarjha@gmail. simple analgesics without any surgical intervention. The case was clinically com diagnosed in the Emergency Department (ED) as CES and an MRI was Received on 09.11.2018, ordered which confirmed the diagnosis. The patient was referred to the Accepted on 03.12.2018 Neurosurgery Department and operated the next day with good clinical outcome. Keywords: Prolapsed inter vertebral disc (PIVD); Cauda Equina Syndrome (CES); Microdiscectomy; Saddle anesthesia; Magnetic Resonance Imaging (MRI); Anal wink; Anal sphincter tone; Bladder and Bowel disturbances; Red Flag signs. Introduction Possible Diagnosis Red flags Vertebral Fractures History of trauma (might be Cauda equina syndrome is a clinical manifestation minimal in the elderly or those resulting due to compression of the nerve roots with osteoporosis) below the termination of the spinal cord (conus Prolonged steroid use medullaris). The cauda equina contains nerve roots Tumor Age <20 or > 50 years from L1-L5 and S1-S5. Malignancy history Non-mechanical pain Causes of cauda equina syndrome include: Thoracic pain 1. Central disc prolapse Systemically unwell patients Weight loss 2. Tumour Spinal Infection Fever 3. Spinal stenosis (e.g. osteoarthiritis, Systemically unwell patients ankylosing spondylitis) i.v. drug use 4. Epidural haematoma (e.g. post-spinal Immunosuppression anaesthesia or lumbar puncture) HIV infected patients Patients with recent bacterial 5. Trauma (blunt or penetrating) infection 6. Spinal epidural abscess [1] Non-mechanical pain The following are the Red ags signs for back pain Pain worsening at night [2]. © Red Flower Publication Pvt. Ltd. 342 Tanmay Kumar Jha, Sarat Kumar Naidu, Dheeraj Bhaskaran Nair / A Case of Delay in Diagnosis of Cauda Equina Syndrome along with Complications; Ideally, a Surgical Emergency Cauda Equina Patients with saddle anesthesia and for planning surgical treatment. The sooner it Syndrome Bladder or bowel dysfunction can be diagnosed, the better is the chance that the Gait disturbance patient makes a better recovery from symptoms Widespread / progressive of nerve damage. It generally requires prompt motor weakness surgical decompression in order to decrease or Bilateral sciatica in patients eliminate pressure on the affected nerves. Surgical AAA Systemically unwell patients decompression is advocated as soon as possible, Cardiovascular compromise within about 8 hours of the onset of symptoms if Pulsatile abdominal mass symptoms develop suddenly. Next to surgery, Inflammatory Age <20 years the extent of recovery is uncertain. Patients may rheumatic disease Structural deformity of the continue to experiencelow back or leg pain, bladder (e.g. ankylosing spine spondylitis) Systemically unwell patients or bowel dysfunction, and other physical problems depending on the duration ofnerve compression It is of two types based on onset; acute and and the severity of symptoms at the time of gradual. If symptoms occur within 24 hours then it surgery. If patients with cauda equina syndromedo is acute in onset and if patient develops symptoms not receive treatment quickly, adverse results after several weeks or months then it is gradual in can include paralysis, impaired bladder and/or onset. MRI (magnetic resonance imaging) is the bowel control, dif culty walking, and/or other standard method of con rming the presence of CES neurological and physical problems. Fig. 1: Indian Journal of Emergency Medicine / Vol. 4 No. 4 / October - December 2018 Tanmay Kumar Jha, Sarat Kumar Naidu, Dheeraj Bhaskaran Nair / A Case of Delay in 343 Diagnosis of Cauda Equina Syndrome along with Complications; Ideally, a Surgical Emergency Case Study discharged in stable condition the next day after procedure with the following discharge advice: A 24-year old male farmer of Indian origin with Tab. Ceftum 500 mg BD for 10 days a history off all from a tractor 6 months back was Tab. Rantac 150 mg BD for 10 days brought to the emergency department at around 05:00 pm by his relatives with complaints of Tab. Flexon MR BD for 3 days then SOS for pain exacerbation of lower backache since one day. Tab. Dexa 2 mg BD for 3 days The patient gave history of falling from a tractor Tab. Nuhenz OD for 10 days 6 months back after which he has had complaints Tab. Bi lac OD for 10 days of lower backache on and off, post voidal retention, urinary hesitancy, dif culty in passing stools, Stitch removal after 2 weeks. dif culty in walking, saddle anaesthesia since then. Patient was followed by the primary author He had multiple visits to other numerous hospitals over telephonic conversation for 8 weeks and the with similar complaints where he was prescribed patient’s symptoms gradually improved over this simple analgesics without a proper diagnosis. period and the patient is symptom free at the end of 8 weeks. Physical examination revealed the patient was conscious and cooperative. His respiratory rate was 18/min. His pulse rate was 80/min, BP was Discussion and Therapeutic Considerations 120/80mmHg, RBS was 119mg/dL, His SpO2 was 99% on room air. Several case series have been reported with He didn’t have any pallor, icterus, cyanosis, varied clinical manifestations like unilateral leg jugular venous distention, pedal edema or symptomatology [3,4], saddle anesthesia with or lymphadenopathy. without leg symptoms and CES with complete absence of signs and symptoms in the lower Cardiovascular, respiratory and per abdominal examinations were insigni cant. His GCS was limbs. O’Laoire reported CES with acute bladder retention and lack of sensory de cit in 2 out of his 15/15. On perineal examination anal wink was absent, anal sphincter tone was reduced and saddle 29 patients [5]. anesthesia was present. Left straight leg raising was Two features make cauda equina susceptible to painfully limited to 30 degrees and on the right to the effects of compressive and tensile forces. First, 40 degrees. Bowstring and Braggards tests were the nerve roots have no Schwann cell covering; positive on the left. Valsalva’s maneuver produced second, cauda equina lacksa regionalised segmental low back and left leg pain. blood supply with relative hypovascularity in A large IV. cannula was inserted in left cubital the central portion of the nerve root, making it vein and samples were taken routine investigations vulnerable to ischaemia from compression [6]. like CBC, LFT, KFT. If compression of the cauda equina develops I.V. analgesics were started to manage pain slowly over aperiod of weeks, months or years, and MRI L-S Spine was ordered in the Emergency patients will present with the history, signs Department and Neurosurgery consultation and symptoms of slow onset CES. Typically, was sought. each episode increases in severity and duration and becomes more resistant to conservative management. In its early phase, presenting signs C ourse in the Hospital and Outcome and symptoms may vary considerably depending A provisional diagnosis of L5/S1 PIVD with on the size and position of the disc herniation. cauda equina syndrome was made which was later Evidence of early sacral nerve root involvement con rmed by MRI reports. may be present, including unilateralor bilateral The patient was planned for microdiscectomy saddle parasthesia, urinary frequency, urgency the next day after pre-anesthetic assessment. and incontinence. In some cases, patients may experience bowel incontinence and impotence. Microdiscectomy was performed the next day Some patients may exhibitearly lumbar radicular by the neurosurgery team in general anesthesia in signs such as lower limb weakness, sensory de cits prone position via median approach. along dermatomal distributions, diminished deep Patient tolerated the procedure well. Post- tendon re exes and referred pain patterns. As the operative period was uneventful. Patient was disc herniation enlarges, both the lumbar and Indian Journal of Emergency Medicine / Vol. 4 No. 4 / October - December 2018 344 Tanmay Kumar Jha, Sarat Kumar Naidu, Dheeraj Bhaskaran Nair / A Case of Delay in Diagnosis of Cauda Equina Syndrome along with Complications; Ideally, a Surgical Emergency sacral roots become compressed and the “classical” Conclusion presentation of CES develops. The slow development of cauda equina Cauda equine syndrome (CES) is a potentially compression may be aconsequence of progressive debilitating syndrome. Emergency physicians degenerative change of the disc. often evaluate patients for low backache but should be aware of signs and symptoms of CES The disc herniations occurs, not only from and if any suspicion of such a diagnosis, MRI sudden, excessive hyper exion injuries, but should be urgently undertaken for con rmation. also as a result of cumulative trauma combined Surgical decompression is the treatment of choice.