Case report
The cauda equina syndrome in pregnant woman with a massive disc herniation
Síndrome de cauda equina en paciente embarazada con hernia de disco masiva
B. Antón Capitán
, M. Malillos Torán
Corresponding author
Unidad de Columna, Hospital San Pedro de Logroño, La Rioja, Spain
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"apellidos" => "Marco" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1888441516300625" "doi" => "10.1016/j.recot.2016.07.002" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1888441516300625?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S198888561630058X?idApp=UINPBA00004N" "url" => "/19888856/0000006100000001/v1_201701150031/S198888561630058X/v1_201701150031/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "The cauda equina syndrome in pregnant woman with a massive disc herniation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "63" "paginaFinal" => "65" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B. Antón Capitán, M. Malillos Torán" "autores" => array:2 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Antón Capitán" "email" => array:1 [ 0 => "borjantoncapi@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Malillos Torán" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Columna, Hospital San Pedro de Logroño, La Rioja, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de cauda equina en paciente embarazada con hernia de disco masiva" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 900 "Ancho" => 900 "Tamanyo" => 145910 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hernial fragment of lumber intervertebral disc obtained after discectomy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Low back pain during pregnancy is a common cause of medical consultation, mechanical and positional overload is its principle cause. Low back pain in pregnant women is very common, however cauda equine syndrome as a consequence of disc herniation is rare (1:10,000).<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Cauda equina syndrome secondary to disc herniation is a very serious complication which is characterised by bilateral sciatalgia, loss of lower limb strength, saddle hypoesthesia and genito-urinary sphincter disturbance.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Treatment is surgical in most cases. Delayed diagnosis and treatment can be a cause of chronic disability secondary to neurological sequelae. Despite the recommendation for emergency surgery, full recovery cannot be guaranteed and sequelae after surgery are relatively common. However, delayed or lack of surgery results in a greater risk of presenting definitive sequelae, which are more serious.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Numerous cases of disc herniation have been described during pregnancy, however associated cauda equina syndrome is rare.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2,4,5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a 39-year-old woman at 12 weeks’ gestation, who presented with at 12-h history of bilateral lumbosciatalgia associated with saddle anaesthesia, urinary incontinence and faecal urgency. The patient's background included a one-year history of chronic backache managed conservatively since it did not find it excessively restrictive. On physical examination she presented tendinous hyporeflexia, positive bilateral Lasègue's sign at 30° and absence of anal reflex.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The lumbar MRI scan showed massive left-sided disc herniation in L4–L5 severely stenosing the vertebral canal (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0030" class="elsevierStylePara elsevierViewall">After assessment by the anaesthesiology and gynaecology departments, the patient was sent for emergency intervention and a left hemilaminectomy and microdiscectomy performed using a posterior approach with the patient in the prone position (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">No complications were observed in the mother or foetus during surgery.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Five months after surgery, the patient was walking normally but presented minimal saddle hypoesthesia and genito-urinary disturbance (repeated urinary infections). The pregnancy proceeded normally and she was expected to give birth imminently.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Cauda equina syndrome is a true medical emergency. The fact that it occurs in a pregnant patient should not contraindicate surgery. It can be operated with good outcomes both for mother and foetus.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2,4,5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the risk of disability, we must rule out this clinical picture in all patients consulting with lumbosciatalgia, including pregnant women. Diagnosis is fundamentally clinical. If there is a suspected sphincter disturbance we should perform rectal examination to test the tone of the anal sphincter. If the anal sphincter is hypotonic, an emergency MRI scan should be requested.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2,4,6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">MRI scans are not contraindicated during gestation and neither is general anaesthetic if it is required by the patient.</p><p id="par0060" class="elsevierStylePara elsevierViewall">If the presence of extruded disc herniation is confirmed treatment should be surgical in the first 24–48<span class="elsevierStyleHsp" style=""></span>h. Urgent decompression can prevent definitive sequelae.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Many studies support the need for emergency decompressive surgery, since spinal compression time is a major prognostic factor. There are other criteria which can predict outcomes: bilateral sciatalgia has less chance of total recovery than unilateral, patients with perineal anaesthesia are more likely to develop vesical sequelae. Saddle anaesthesia is the most significant predictive factor of recovery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Special care should be taken in positioning the patient to prevent excessive abdominal compression.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,6–9</span></a> In our case a microdiscectomy was performed with the patient in the prone position, no complications were observed in the mother or the foetus. Although the operation was undertaken as an emergency, the patient presented sequelae likely to have been less serious than if surgery had not been performed or if it had been delayed more than 48<span class="elsevierStyleHsp" style=""></span>h.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In summary, clinical pictures of backache during pregnancy are very frequent and are treated conservatively. However, we should perform an MRI scan for sudden-onset lumbosciatalgia associated with loss of strength, sphincter disturbance or saddle hypoesthesia. If the patient develops associated gradual neurological deficit and/or signs and symptoms compatible with cauda equina syndrome, emergency decompressive surgery should be performed to minimise neurological sequelae.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Level of evidence</span><p id="par0080" class="elsevierStylePara elsevierViewall">Level of evidence IV.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Protection of people and animals</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that neither human nor animal testing have been carried out under this research.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Confidentiality of data</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with their work centre protocols for the publication of patient data.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patients’ data appear in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres789252" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec787647" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres789251" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec787646" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Level of evidence" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-25" "fechaAceptado" => "2015-05-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec787647" "palabras" => array:3 [ 0 => "Cauda equina syndrome" 1 => "Herniated disc" 2 => "Pregnancy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec787646" "palabras" => array:3 [ 0 => "Síndrome de cauda equina" 1 => "Hernia discal" 2 => "Embarazo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Low back pain during pregnancy is a common cause of medical consultation. Although back pain is very common, the incidence of low back pain secondary to lumbar disc herniation in pregnancy is low (1:10,000).</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cauda equina syndrome from lumbar disc herniation is a serious complication. The delay in diagnosis and treatment can be a cause of chronic disability secondary to neurological sequelae. Numerous cases of disc herniation in pregnancy have been reported, however the association of a cauda equina syndrome as a result of disc herniation is rare. A case is presented of cauda equina syndrome in a pregnant woman at 12-week gestation.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La lumbalgia durante el embarazo supone una causa frecuente de consulta médica. Si bien la lumbalgia es muy frecuente, la incidencia de lumbalgia secundaria a hernia discal durante la gestación es baja (1:10.000).</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El síndrome de cauda equina secundaria a hernia discal representa una complicación muy grave. El retraso en el diagnóstico y en el tratamiento puede suponer una causa de discapacidad crónica secundaria a secuelas neurológicas. Se han comunicado numerosos casos de hernias discales durante el embarazo, sin embargo la asociación de un síndrome de cauda equina por hernia discal es poco frecuente. Presentamos el caso de un síndrome de cauda equina en una mujer embarazada de 12 semanas de gestación.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Antón Capitán B, Malillos Torán M. Síndrome de cauda equina en paciente embarazada con hernia de disco masiva. Rev Esp Cir Ortop Traumatol. 2017;61:63–65.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 807 "Ancho" => 1400 "Tamanyo" => 157561 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(a) Sagittal slice MRI: extruded disc herniation L4–L5 with caudal migration. (b) Axial slice MRI: left paracentral disc herniation touching the nerve root and retracting the dural sac.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 900 "Ancho" => 900 "Tamanyo" => 145910 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Hernial fragment of lumber intervertebral disc obtained after discectomy.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lumbar disk herniation presented with cauda equine syndrome in a pregnant woman" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 27 | 10 | 37 |
| 2024 September | 27 | 20 | 47 |
| 2024 August | 39 | 20 | 59 |
| 2024 July | 40 | 10 | 50 |
| 2024 June | 28 | 7 | 35 |
| 2024 May | 22 | 4 | 26 |
| 2024 April | 33 | 1 | 34 |
| 2024 March | 36 | 7 | 43 |
| 2024 February | 79 | 8 | 87 |
| 2024 January | 66 | 5 | 71 |
| 2023 December | 52 | 4 | 56 |
| 2023 November | 71 | 9 | 80 |
| 2023 October | 119 | 7 | 126 |
| 2023 September | 51 | 6 | 57 |
| 2023 August | 56 | 5 | 61 |
| 2023 July | 73 | 6 | 79 |
| 2023 June | 82 | 14 | 96 |
| 2023 May | 135 | 26 | 161 |
| 2023 April | 78 | 20 | 98 |
| 2023 March | 70 | 7 | 77 |
| 2023 February | 56 | 24 | 80 |
| 2023 January | 57 | 10 | 67 |
| 2022 December | 64 | 7 | 71 |
| 2022 November | 56 | 6 | 62 |
| 2022 October | 49 | 10 | 59 |
| 2022 September | 43 | 24 | 67 |
| 2022 August | 48 | 12 | 60 |
| 2022 July | 22 | 12 | 34 |
| 2022 June | 28 | 11 | 39 |
| 2022 May | 18 | 13 | 31 |
| 2022 April | 45 | 9 | 54 |
| 2022 March | 65 | 6 | 71 |
| 2022 February | 42 | 10 | 52 |
| 2022 January | 73 | 12 | 85 |
| 2021 December | 45 | 8 | 53 |
| 2021 November | 39 | 9 | 48 |
| 2021 October | 81 | 17 | 98 |
| 2021 September | 58 | 10 | 68 |
| 2021 August | 62 | 14 | 76 |
| 2021 July | 58 | 8 | 66 |
| 2021 June | 28 | 8 | 36 |
| 2021 May | 38 | 11 | 49 |
| 2021 April | 69 | 11 | 80 |
| 2021 March | 28 | 9 | 37 |
| 2021 February | 26 | 23 | 49 |
| 2021 January | 21 | 5 | 26 |
| 2020 December | 1 | 2 | 3 |
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