Cauda Equina Syndrome During Labour - A Diagnostic Challenge and Proposed Management Algorithm

Author(s): Nicholas B Jones BSc(Hons), MBChB; Jonathon Richards MBChB, FRACS (Ortho); Christopher Hoffman MBChB, FRACS (Ortho); Shay Mandler MD, Cert Spec (Orth)

Aim:

The incidence of lumbar disc herniation during pregnancy is rare (1:10,000). Of all lumbar disc herniation’s, only 2% will develop acute Cauda Equina Syndrome (CES). It is a diagnostic challenge to identify CES during labour due to overlapping symptoms that mimic and obscure CES symptoms in a stressful therapeutic environment. We present a case report and brief literature review with a proposed algorithm for management.

Method:

We reviewed the case of a nulliparous 35 year old woman who developed CES during labour due to an acute extruded disc. CES symptoms developed during labour and were initially attributed to the obstetric process. Baby was delivered via emergency caesarean section for prolonged labour and foetal distress. Post delivery persistent saddle paresthesia, urinary retention and radicular leg pain prompted orthopaedic review. An MRI was performed demonstrating a large disc extrusion at the level of L5/S1.

Results:

Emergent decompression was performed post partum day 7. Improving pain and neurologic deficits were seen initially but some ongoing perineal parathesia and urinary frequency.

Conclusion:

Maintaining a high index of suspicion for persistent saddle anaesthesia, urinary retention and radicular pain post partum would aide in early referral for Orthopaedic review and advanced imagining in CES. The hope is this will help prevent persistent neurological deficits in young women and case reporting will aide in understanding what role if any CES has in prolonged labour.