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Acute Disc Herniation with Cauda Equina Syndrome in the Setting of a Labor Epidural
Abstract Number: SA-51
Abstract Type: Case Report/Case Series
Case: A 35-year-old G5P4 female at 40week EGA presented to L&D in active labor. At the patient's request, an epidural was placed at the L4-L5 interspace with LOR at 6.5 cm. A catheter was threaded 5 cm into the epidural space. Aspiration was negative for heme and CSF. Test dose was negative. An epidural infusion of 0.1% bupivacaine with 2 mcg fentanyl per ml was started. After 4 hours, she developed left sided pain. The catheter was withdrawn 1 cm and bolused with 5 ml of 0.0125% bupivacaine with improvement in pain. She had an uneventful vagninal delivery. 2 hours later, her epidural catheter was removed. The patient reported residual paresthesia in her right foot but motor strength was intact. 7 hours later, the patient was unable to lift her leg or flex her knee. She had a right sided sensory block from T10 to toes. Sensation on the left was normal. She also complained of 7/10 lumbar back pain. Epidural hematoma was suspected. A STAT MRI of lumbar-spine was obtained, demonstrating posterior disc extrusion at L5-S1 causing marked central spinal and neural foraminal stenosis. The orthopaedic surgical team was consulted. The patient was taken to the OR the next day for L5-S1 discectomy. Postoperatively, the patient had slow recovery of RLE sensation and motor function and was discharged from the hospital on POD 4.
Discussion: Acute lumbar disc herniation has a prevalence of 1 in 10,000 pregnancies. Less than 2% of lumbar disc herniations result in cauda equina syndrome (CES), which requires emergent surgical decompression(1). Acute disc herniation with CES during labor and delivery is an even more rare presentation. There are only a few cases described in the past (2). This is the first report of acute disc herniation with CES during labor with a concurrent epidural. In our case, the overlap of epidural placement with the onset of disc herniation made the correct diagnosis very difficult. Furthermore, the residual paraesthesia from an epidural could last over 24 hours, which makes early diagnosis a daunting task. Early diagnosis is key for early surgery and improved outcome with more neurological recovery. This highlights the importance of thorough post epidural neurological exams.
1. Bhardwaj, Nagandla A. "Musculoskeletal Symptoms and Orhtopaedic Complications in Pregnancy:
Pathophysiology, Diagnostic Approaches and Modern Management." Postgrad Med Journal 90.1066
2. Jones, CS, et al. "Presentation of Cauda Equina Syndrome during Labour." BMJ Case Report (2015).