Rare case of Cauda equina in pregnancy, the diagnostic and management dilemmas.

Misbah Malik1, Androniks Mumdzjans2, Slavyana Maydanovych3

CASE REPORT: 24 years, previous 2 vaginal deliveries, 36+4 weeks, known L3/L4 disc bulge, admitted with increased pain on left back radiating to buttock, struggling to walk with pain and new onset urinary incontinence.

MRI spine lumbar and sacral concluded that transition vertebra at L5/S1 with lumbarised S1. Large broad based central and left paracentral disc extrusion causing significant compression of the thecal sac and left S1 nerve root with crowding and compression of cauda equina and abutting the right S1 nerve root.

Neurosurgical team involved. Next day patient had emergency caesarean section with baby weight 2490g. 2 days later had L5/S1 discectomy and decompression by right- sided keyhole approach to central disc prolapse. Indication of impending cauda equina syndrome.

DISCUSSION:

Lumbar disc herniations have an incidence of 1:10 000 and less than 2% of these herniations result in cauda equina syndrome (CES), making it a rare condition in pregnancy. The bowel and bladder symptoms are quite common in pregnancy and so arises the dilemma of when to start the diagnostic tests as MRI is diagnostic for Cauda equina1. Due to the risk of permanent neurological damage, it is considered an emergency2. Another case series reported cases of cauda equina at 24,27 and 30 weeks and all underwent decompression in prone position3. In our patient as she was close to term, a combined plan by Obstetrician and neurosurgeon of caesarean section first and then proceeding for discectomy and decompression was made mostly because of the challenge of position during this surgery. During surgery she was prone in the knee chest position to avoid pressure over the incision and postpartum uterus. She is currently under Spinal injuries team.

CONCLUSION:

The dilemmas in this case were firstly the diagnosis as it is a rare condition, management in the form of emergency surgery and then balancing the risks and benefits of continuation of pregnancy or delivery.