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Perioperative management of cauda equina syndrome in pregnancy.
Abstract Number: FCI-507
Abstract Type: Case Report Case Series
Cauda equina syndrome is a rare condition associated with lower extremity weakness and sensory deficits. It is caused by external compression of the cauda equina, which is a bundle of spinal nerves extending from the conus medullaris at L1. Here we describe a case of CES in late pregnancy requiring urgent intervention
A 37 year old female G5P2112 at 32w3d transferred higher acuity care for chronic hypertension with superimposed preeclampsia, undifferentiated breast mass, and L3 compression fracture resulting in cauda equina syndrome.
The patient has a history of 2 cm x 2 cm left breast mass found approximately 5 months prior to presentation that was initially being followed by serial ultrasounds. Due to the pregnancy and difficulty keeping appointments, she did not follow up as directed.
Then approximately 3 weeks prior to presentation the patient had a fall down two stairs and since then has had worsening back pain and bilateral lower extremity weakness. She eventually went to the emergency room and was found to have severe range blood pressures with elevated AST and ALT on labs.
On initial imaging of her lumbar spine she was found to have likely metastatic disease at T12 and L3. She was found to have an L3 pathological burst fracture with retropulsion causing complete effacement of the canal. On exam she had fecal incontinence, LLE global weakness, and absent bilateral plantar and Achilles reflexes.
After multidisciplinary planning, she underwent cesarean for delivery under general anesthesia followed by emergent spinal cord decompression.
Cauda Equina Syndrome
Two clinical categories:
1. Cauda equina with retention: presents with urinary retention
2. Incomplete cauda equina syndrome: reduced urinary sensation, loss of desire to void, but no overflow incontinence or urinary retention
Presentation and diagnosis:
• Can have acute onset, progression from chronic back pain or insidious onset
• Clinical diagnosis and must include bladder, bowel, or sexual dysfunction and “saddle” anesthesia
• Can also include lower extremity weakness or sensory changes, reduction in lower extremity reflexes, and have a unilateral or bilateral distribution.
• Typically CT or MRI are used to confirm cauda equina compression
• Surgical decompression is indicated when a reversible cause is identified
• Patient with incomplete CES may have better improved outcomes after surgery
Considerations in pregnancy
• Diagnosis: Can be difficult as some clinical symptoms are normal in pregnancy
• Positioning: surgical decompression often is urgently necessary in the prone position. Abdominal compression is poorly tolerated in the fetus in later part of pregnancy and delivery may be necessary before neurosurgical intervention
Cauda Equina Syndrome. BMJ. 2009; 338(7699):881-4.
Cauda equina syndrome during pregnancy: a condition to consider. Int J of Surg. 2018; 48:14-16.
Presentation of cauda equina syndrome during labour. BMJ Case Rep. 2015; 1-3