Kapil Shinde
East Kent Hospitals, United KingdomPresentation Title:
Emergency Surgery for Cauda Equina Syndrome in a Third Trimester Pregnant Woman
Abstract
This case report details the presentation, diagnosis, and management of a third-trimester pregnant woman who developed cauda equina syndrome (CES), necessitating emergency surgery. The case emphasizes the challenges in diagnosing and managing CES in a pregnant patient and underscores the importance of prompt surgical intervention to prevent permanent neurological deficits.
Introduction: Cauda equina syndrome (CES) is a rare but serious condition characterized by compression of the cauda equina nerves in the lumbosacral spine, leading to motor and sensory deficits in the lower extremities, bladder and bowel dysfunction, and perineal numbness. In pregnant women, the diagnosis and treatment of CES are complicated by physiological changes and concerns for fetal well-being. This report describes a case of CES in a third-trimester pregnant woman who underwent emergency decompressive surgery.
Case Presentation: A 34-year-old woman, gravida 2 para 1, at 32 weeks’ gestation, presented to the emergency department with acute onset of severe lower back pain radiating to both legs, bilateral lower extremity weakness, numbness in the perineal area, and urinary retention. The symptoms had progressively worsened over 48 hours. She had no history of trauma or previous spinal issues.
Clinical Examination: On examination, the patient was in distress due to severe pain. Neurological examination revealed decreased strength (Grade 2/5) in both lower extremities, absent deep tendon reflexes at the knees and ankles, and reduced sensation in the saddle area. Rectal examination confirmed decreased anal sphincter tone. Fetal heart rate monitoring indicated a normal baseline with no signs of distress.
Investigations: Given the high suspicion of CES, an urgent MRI of the lumbar spine was performed, which revealed a large herniated disc at L4-L5 causing significant compression of the cauda equina.
Management: The patient was immediately referred to neurosurgery for emergency decompressive laminectomy. The risks of surgery and anesthesia, both to the mother and the fetus, were discussed extensively with the patient and her family. Given the progressive neurological deficits and the potential for permanent damage, the decision was made to proceed with surgery.
Surgical Procedure: Under general anesthesia, the patient underwent an L4-L5 laminectomy with discectomy. Intraoperative fetal monitoring was continued, and the surgery was uneventful. The herniated disc material was successfully removed, relieving the compression on the cauda equina.
Postoperative Course: Postoperatively, the patient was monitored in the intensive care unit with continuous fetal monitoring. She received intravenous fluids, analgesics, and thromboprophylaxis. By the second postoperative day, she reported improvement in pain and partial return of motor function in the lower extremities. Bladder catheterization was continued due to persistent urinary retention.
Outcome and Follow-Up: By one week post-surgery, the patient regained significant motor function (Grade 4/5) in her legs and began to ambulate with assistance. Sensation in the perineal area improved gradually, and she regained some voluntary control over bladder function. The pregnancy continued without complications, and she delivered a healthy baby at 38 weeks gestation via elective cesarean section.
Discussion: This case highlights the importance of early recognition and intervention in CES, especially in pregnant patients where diagnostic and therapeutic options are limited by fetal considerations. MRI remains the gold standard for diagnosis, and emergency decompression is crucial to prevent irreversible neurological damage. Multidisciplinary management involving obstetricians, anesthesiologists, and neurosurgeons is essential for optimal outcomes.
Conclusion: Cauda equina syndrome in pregnancy is a rare but critical condition requiring prompt diagnosis and surgical intervention. This case demonstrates that with timely and coordinated care, favorable maternal and fetal outcomes can be achieved despite the complexities involved.
Biography
Kapil Shinde is an orthopaedic trainee at East Kent Hospitals, dedicated to delivering high-quality musculoskeletal care. With a passion for education, he actively engages in teaching at Kent and Medway Medical School, imparting his knowledge to medical students and residents. Dr Kapil is also deeply involved in clinical research, focusing on innovative treatments and improving surgical outcomes. His work has contributed to peer-reviewed publications, showcasing his commitment to advancing orthopaedic practice. Through his dual roles in clinical care and academia, Dr.Kapil aims to enhance patient outcomes and mentor the next generation of medical professionals.
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