Case Report of International Journal of Case Reports
Acute cauda equina syndrome due to lumbar spinal stenosis caused by prolonged supine position during cardiac catheterization: a case report
Kazuki Kobayashi, Kazuyuki Watanabe, Kinshi Kato, Michiyuki Hakozaki, Jun-ichi Handa, Hiroshi Kobayashi, Takuya Nikaido, Koji Otani, Shoji Yabuki, and Shin-ichi Konno
Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
Background: Cauda equina syndrome (CES) is a severe neurologic condition marked by progressive loss of function of the neurologic elements in the spinal canal below the termination of the spinal cord. This article reports an instructive case of CES with acute aggravation of neuropathy after catheter ablation for atrial fibrillation.
Patient concerns: A 63-year-old Japanese man underwent catheter ablation for atrial fibrillation. Because he complained of severe low back pain and numbness in the posterior of both lower limbs while in the supine position, he was given analgesia with pentazocine and sedated with propofol, and the procedure continued. He was then forced to maintain lumbar extension while in the supine position for 13 hours. After the treatment, he noticed urination disor-der, numbness, and paralysis of both lower limbs.
Diagnosis: Neurological findings included sensory impairment and motor deficit of L5 and below, including bowel/bladder dysfunction. Lumbar magnetic resonance imaging showed severe lumbar spinal stenosis at L4-L5. He was diagnosed with CES due to lumbar spinal stenosis.
Interventions: The patient received emergency surgery for L4-L5 decompression. Decompression of the spinal canal was achieved 33 hours after the start of catheterization.
Outcomes: The patient’s leg symptoms improved immediately after surgery, and he was able to walk with a walker. On postoperative day 6, the urinary catheter was removed. However, he experienced urinary retention and needed intermittent self-directed urination. Five months after surgery, he was able to urinate on his own, and completed the intermittent self-directed urination. Nine months after surgery, his muscle strength had recovered almost completely, and he was able to walk with a cane. However, bladder dysfunction such as frequent urination and residual urination remained 4 years after surgery.
Lessons: If the supine position elicits low back pain and leg numbness, the presence of lumbar spinal stenosis should be considered. Forcing patients with such symptoms into a sustained posture can lead to CES.
Keywords: cauda equina syndrome, lumbar spinal stenosis, supine position, cardiac catheterization
How to cite this article:
Kazuki Kobayashi, Kazuyuki Watanabe, Kinshi Kato, Michiyuki Hakozaki, Jun-ichi Handa, Hiroshi Kobayashi, Takuya Nikaido, Koji Otani, Shoji Yabuki, Shin-ichi Konno. Subclinical chronic sinusitis causing presumed ventriculoperitoneal shunt sepsis in a child. International Journal of Case Reports, 2021 5:209. DOI: 10.28933/ijcr-2021-03-3006
1. Quaile A. Cauda equina syndrome – the questions. Int Orthop. 2019; 43(4): 957-961.
2. Rigler ML, Drasner K, Krejcie TC, et al. Cauda equina syndrome after continuous spinal anesthesia. Anesth Analg. 1991; 72: 275-281.
3. David B. Cohen. Infectious origins of cauda equina syndrome. Neurosurgical Focus. 2004; 16(6): 5-10.
4. He F, Xing T, Yu F, Li H, Fang X, Song H. Cauda equina syndrome: an uncommon symptom of aortic diseases. Int J Clin Exp Med. 2015; 15;8(7): 10760-10766.
5. Johnsson KE, Sass M. Cauda equina syndrome in lumbar spinal stenosis: case report and incidence in Jutland, Denmark. J Spinal Disord Tech. 2004; 17(4): 334-335.
6. Kebaish KM, Awad JN. Spinal epidural hematoma causing acute cauda equina syndrome. Neurosurgical Focus. 2004; 16(6): 1-2.
7. Kapetanakis S, Chaniotakis C, Kazakos C, Papathanasiou JV. Cauda equina syndrome due to lumbar disc herniation: a review of literature. Folia Med (Plovdiv). 2017; 59(4): 377-386.
8. Todd NV. Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg. 2005; 19(4): 301-306.
9. Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. Spine. 2000; 25: 1515-1522.
10. Forestier J, Rotes-Querol J. Senile ankylosing hyperostosis of the spine. Ann Rheum Dis. 1950; 9(4): 321-330.
11. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J. Bone Joint Surg. 1954; 36: 230-237.
12. Ishimoto Y, Yoshimura N, Muraki S, et al. Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population-based cohort in Japan: the Wakayama Spine Study. Osteoarthritis Cartilage. 2012; 20(10): 1103-1108.
13. Yabuki S, Fukumori N, Takegami M, et al. Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study. J Orthop Sci. 2013; 18(6): 893-900.
14. Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine. 2009; 9(7): 545-550.
15. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008; 358(8): 818-825.
16. Konno S, Kikuchi S, Tanaka Y, et al. A diagnosis support tool for lumbar spinal stenosis: a self-administrated, self-reported history questionnaire. BMC Muscloskelet Disord. 2007; 8: 102.
17. Watanabe K, Sekiguchi M, Yonemoto K, et al. Bowel/bladder dysfunction and numbness in the sole of the both feet in lumbar spinal stenosis – A multicenter cross-sectional study. J Orthop Sci. 2017; 22(4): 647-651.
18. Takahashi K, Miyazaki T, Takino T, Matsui T, Tomita K. Epidural pressure measurements: relationship between epidural pressure and posture in patients with lumbar spinal stenosis. Spine. 1995; 20(6): 650-653.
19. Takahashi N, Kikuchi S, Yabuki S, Otani K, Konno S. Diagnostic value of the lumbar extension-loading test in patients with lumbar spinal stenosis: a cross-sectional study. BMC Musculoskelet Disord. 2014; 15: 259.
20. Sekiguchi M, Kikuchi S, Myers RR. Experimental spinal stenosis: relationship between degree of cauda equina compression, neuropathology, and pain. Spine. 2004; 29(10): 1105-1111.
21. Iwamoto H, Kuwahara H, Matsuda H, Noriage A, Yamano Y. Production of chronic compression of the cauda equina in rats for use in studies of lumbar spinal canal stenosis. Spine. 1995; 20(24): 2750-2757.
22. Porter RW. Spinal stenosis and neurogenic claudication. Spine. 1996; 21(17): 2046-2052.
23. Ooi Y, Mita F, Satoh Y. Myeloscopic study on lumbar spinal canal stenosis with special reference to intermittent claudication. Spine. 1990; 15(6): 544-549.
24. Porter RW, Ward D. Cauda equina dysfunction. The significance of two-level pathology. Spine. 1992; 17(1): 9-15.
25. Sakellariou VI, Papadopoulos EC, Babis GC. Uncommon complication after revision hip surgery. Orthopedics. 2014; 37(6): e608-612.
26. Chagnas MO, Poiraudeau S, Lefèvre-Colau MM, Rannou F, Nguyen C. Diagnosis and management of lumbar spinal stenosis in primary care in France: a survey of general practitioners. BMC Musculoskelet Disord. 2019; 20(1): 431.