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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 34  |  Issue : 2  |  Page : 131-133

Cauda equina syndrome in a postoperative patient of total hip replacement surgery: Possible exacerbation due to extreme intraoperative manipulation


Department of Anaesthesiology, AIIMS, Raipur, Chhattisgarh, India

Date of Submission08-Apr-2020
Date of Decision02-May-2020
Date of Acceptance07-May-2020
Date of Web Publication06-Aug-2020

Correspondence Address:
Dr. Samarjit Dey
Department of Anaesthesiology, AIIMS, Raipur - 492 099, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_43_20

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  Abstract 


Cauda equina syndrome (CES) is a rare but devastating complication, which warrants an urgent or emergency decompressive surgery. To diagnose it early and also, a timely intervention can halt neurological sequelae. More common causes for CES include chronic disc diseases, spinal injury, and fractures. However, there are less common causes such as spinal manipulation, tuberculosis, and spinal tumors. Here, we report a rare cause of CES precipitated by extreme manipulation of the spine during total hip replacement surgery done under neuraxial blockade. This condition was diagnosed by the acute pain service team at an early stage and successfully treated with emergency decompressive surgery to avert any further neurological complications.

Keywords: Cauda equina syndrome, low back pain, total hip replacement


How to cite this article:
Mujahid OM, Dey S, Iqbal J, Mistry T, Kalbande J, Khetarpal M. Cauda equina syndrome in a postoperative patient of total hip replacement surgery: Possible exacerbation due to extreme intraoperative manipulation. Indian J Pain 2020;34:131-3

How to cite this URL:
Mujahid OM, Dey S, Iqbal J, Mistry T, Kalbande J, Khetarpal M. Cauda equina syndrome in a postoperative patient of total hip replacement surgery: Possible exacerbation due to extreme intraoperative manipulation. Indian J Pain [serial online] 2020 [cited 2020 Nov 26];34:131-3. Available from: https://www.indianjpain.org/text.asp?2020/34/2/131/291544




  Introduction Top


Cauda equina syndrome (CES) is rare, but devastating if symptoms persist. The most common cause of CES in our practice and the focal causative condition in the literature is compression arising from large central lumbar disc herniation at the L4-5 and L5-S1 level.[1] Acute disc herniation (prolapse or rupture) is much less common but considerably more symptomatic than chronic degeneration, often an emergency if the protrusion causes cauda equina compression syndrome. Here, we report an unusual case of precipitation of disc herniation leading to CES due to extreme manipulation in a case of total hip replacement done under neuraxial anesthesia.


  Case Report Top


A 50-year-old male with a working diagnosis of avascular necrosis of the right hip along with femoroacetabular impingement was posted for total hip replacement under ASA physical status II. Neurological examination did not reveal any abnormality.

After shifting to the operating room, standard ASA monitors were connected. Under aseptic precautions, epidural catheter was placed at the L2-L3 space, and using a 25G Quincke's needle, subarachnoid block was given at L2-L3 space with 3 ml of 0.5% bupivacaine (heavy). Block was achieved up to T6 level. Urinary bladder catheterization was done with Foley's catheter. The intraoperative period was uneventful with stable hemodynamic. The surgery was uneventful, and the total duration of the surgery was 2 h and 10 min. The patient was shifted to the postanesthesia care unit and shifted to the ward after 2 h.

Postoperatively, epidural infusion at 5 ml/h (using 0.2% ropivacaine) was started and continued till 48 h, and then, it was removed and analgesia using paracetamol 1 g three times a day; tablet tramadol 50 mg twice daily was a part of the multimodal analgesia regimen postoperatively. On postoperative day 4, the patient started complaining of mild back pain and bowel incontinence with complaints of loss of bowel control and passing of stools unexpectedly, along with complaints of urinary retention.

The motor power in both the lower limbs at that time was 5/5. An urgent magnetic resonance imaging of the lumbosacral spine was ordered, which showed a prolapsed intervertebral disc at L4-L5 level and L5-S1, compressing over CES [Figure 1].
Figure 1: T2-weighted magnetic resonance imaging images of the lumbar spine. (a) Sagittal image showing the posterior bulge of L4-5 and L5-S1 intervertebral discs nearly completely obliterating the thecal sac and compressing on the cauda equina. (b) Axial image showing severe canal stenosis with obliteration of the thecal sac at L4-5

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On further examination and elicitation of history from the patient, he gave a history of occasional low back pain, radiating to the foot and ankle 15 years ago, which was managed conservatively and required no further treatment. He was then taken up for emergency decompressive discectomy and was discharged after 7 days after full recovery and kept on follow-up.


  Discussion Top


The etiology behind a prolapsed intervertebral disc is due to biochemical changes and due to mechanical overload, compounded by old age where the disc is undergoing degenerative changes and by heavy mechanical labor.[2] A combination of flexion and compression is a proximate cause leading to protrusion of a disc. A wide range of iatrogenic causes of CES are reported, including manipulation of the lumbar spine.[1]

Tandon and Sankaran[3] described three variations of CES:

  1. Rapid onset without a previous history of back problems
  2. Acute bladder dysfunction with a history of low back pain and sciatica
  3. Chronic backache and sciatica with gradually progressing CES often with canal stenosis.


It is evident that the onset of CES may be either acute within hours or gradual over weeks or months, and within these groups, CES may be complete with painless incontinence or incomplete with some sphincter function.

Bowel and bladder dysfunction commonly affect patients with spinal cord injuries. As per the Lapides classification system, a reflex neurogenic bladder is caused by complete motor and sensory interruption between the sacral spinal cord and brainstem that is caused due to a spinal cord injury commonly. This manifests as inability to voluntarily initiate voiding and lack of bladder sensation.[4],[5] Neurogenic bowel dysfunction (NBD) also manifests after spinal cord injury, presents as bloating, abdominal discomfort, and distension.

Lower gastrointestinal symptoms include either constipation or fecal incontinence. NBD manifests based on the level of injury. Injuries at the conus medullaris and cauda equina result in a lower motor neuron lesion, affecting the parasympathetic cell bodies in the conus medullaris, the cauda equina, or the pelvic nerve resulting in loss of centrally mediated motor activity, leading to slow bowel transit and an atonic external anal sphincter.[6]

Total hip arthroplasty is done through various approaches, most commonly being a direct lateral approach. Dislocation of the hip under anesthesia involves flexing, adducting, and gently internally rotating the hip and driving the femur against the posterior edge of the acetabulum. Sometimes, the hip does not dislocate and requires considerable force to flex the hip.[7] Considerable amount of compressive force is applied at the time of acetabular reaming and acetabular cup insertion.

Throughout the process of hip arthroplasty, when the patient is under neuraxial anesthesia, a considerable amount of movement is applied at the hip joint, which is transmitted to the lower back region, which in turn, could exacerbate any preexisting process as is seen in our patient. As seen here, the patient developed symptoms of neurogenic bladder and bowel on postoperative day 4 when he was planned to be mobilized. However, a prompt diagnosis and intervention could avert the complications in time.

We should keep in mind to examine the back and elicit the history of back pain or any lower back pathology, and a complete neurological examination in preanesthetic checkup clinic is desirable to identify the at-risk patients who are to be operated under neuraxial anesthesia to prevent such complications like CES. Another point is to limit extreme flexion or extension during manipulation of the spine under anesthesia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflict of interest.



 
  References Top

1.
Chris L, Andrew J, James WM, Jeremy F. Cauda equina syndrome BMJ 2009;338:B936.  Back to cited text no. 1
    
2.
Adams MA, Hutton WC. The mechanics of prolapsed intervertebral disc. Int Orthop 1982;6:249-53.  Back to cited text no. 2
    
3.
Tandon PN, Sankaran B. Cauda equina syndrome due to lumbar disc prolapse. Indian J Orthop 1967;1:112-9.  Back to cited text no. 3
    
4.
Nygaard I, Kreder K. Urological management in patients with spinal cord injuries. Spine 1996;21:128-32.  Back to cited text no. 4
    
5.
Martinez L, Neshatian L, Khavari R. Neurogenic bowel dysfunction in patients with neurogenic bladder. Curr Bladder Dysfunct Rep 2016;11:334-40.  Back to cited text no. 5
    
6.
Qi Z, Middleton JW, Malcolm A. Bowel dysfunction in spinal cord injury. Curr Gastroenterol Rep 2018;20:47.  Back to cited text no. 6
    
7.
Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: Anatomy, technique and clinical outcomes. Can J Surg 2015;58:128-39.  Back to cited text no. 7
    


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