Intervertebral intradural lumbar disc herniation (ILDH) is a quite rare pathology, and isolated intradural lumbar disc herniation is even more rare. Magnetic resonance imaging (MRI) may not be able to reveal ILDHs, especially if MRI findings show an intact lumbar disc annulus and posterior longitudinal ligament. Here, we present an exceedingly rare case of an isolated IDLH that we initially misidentified as a spinal intradural tumor, in a 54-year-old man hospitalized with a 2-month history of back pain and right sciatica. Neurologic examination revealed a positive straight leg raise test on the right side, but he presented no other sensory, motor, or sphincter disturbances. A gadolinium-enhanced MRI revealed what we believed to be an intradural extramedullary tumor compressing the cauda equina leftward in the thecal sac, at the L2 vertebral level. The patient underwent total L2 laminectomy, and we extirpated the intradural mass under microscopic guidance. Histologic examination of the mass revealed a degenerated nucleus pulposus.
Intradural disc herniation; Spinal intradural tumor; Magnetic resonance imaging
Intradural lumbar disc herniation (ILDH) is rare. In this report, authors present 2 cases of ILDHs associated with severe adhesion between the dural sac and posterior longitudinal ligament. In a 40-year-old man, ILDH occurred in association with epidural adhesion due to ossification of the posterior longitudinal ligament (OPLL). In other 31-year-old man, ILDH occurred in presence of epidural adhesion due to previous spine surgery.
Intradural lumbar disc herniation; Ossification of posterior longitudinal ligament; Epidural adhesion
Incidental or intentional durotomy causing cerebrospinal fluid (CSF) leakage, leading to the formation of a pseudomeningocele is a known complication in spinal surgery. Herniation of nerve roots into such a pseudomeningocele is very rare, but can occur up to years after initial durotomy and has been described to cause permanent neurologic deficit. However, cauda equina fiber herniation and entrapment into a pseudomeningocele has not been reported before. Here, we present a case of symptomatic transdural cauda equina herniation and incarceration into a pseudomeningocele, 3 months after extirpation of a lumbar Schwannoma. A 59-year-old man, who previously underwent intradural Schwannoma extirpation presented 3 months after surgery with back pain, sciatica and loss of bladder filling sensation caused by cauda equina fiber entrapment into a defect in the wall of a pseudomeningocele, diagnosed with magnetic resonance imaging. On re-operation, the pseudomeningocele was resected and the herniated and entrapped cauda fibers were released and replaced intradurally. The dura defect was closed and the patient recovered completely. In conclusion, CSF leakage can cause neurological deficit up to years after durotomy by transdural nerve root herniation and subsequent entrapment. Clinicians should be aware of the possibility of this potentially devastating complication. The present case also underlines the importance of meticulous dura closure in spinal surgery.
Pseudomeningocele; Dura defect; Nerve root entrapment
A 73-year-old male presented with a rare dorsally sequestrated lumbar disc herniation manifesting as severe radiating pain in both leg, progressively worsening weakness in both lower extremities, and urinary incontinence, suggesting cauda equina syndrome. Magnetic resonance imaging suggested the sequestrated disc fragment located in the extradural space at the L4-L5 level had surrounded and compressed the dural sac from the lateral to dorsal sides. A bilateral decompressive laminectomy was performed under an operating microscope. A large extruded disc was found to have migrated from the ventral aspect, around the thecal sac, and into the dorsal aspect, which compressed the sac to the right. After removal of the disc fragment, his sciatica was relieved and the patient felt strength of lower extremity improved.
Lumbar disc herniation; Dorsal; Intradural; Migrated
Intradural disc herniation (IDDH) is a rare complication of intervertebral disc disease and comprises 0.26-0.30% of all herniated discs, with 92% of them located in the lumbar region (1). We present a case of IDDH that presented with intermittent symptoms and signs of cauda equina compression. We were unable to find in the literature, any previously described cases of intermittent cauda equina compression from a herniated intradural disc fragment leading to a “floppy disc syndrome”.
Although the most common aetiology of cauda equina lesions is lumbar intervertebral disc herniation, iatrogenic lesions may also be the cause. The aim of this study was to identify and present patients in whom cauda equina lesions occurred after spinal surgery. From the author’s series of patients with cauda equina lesions, those with the appearance of sacral symptoms after spinal surgery were identified. To demonstrate lesions more objectively, electrodiagnostic studies were performed in addition to history and clinical examination. Imaging studies were also reviewed. Of 69 patients from the series, 11 patients in whom a cauda equina lesion developed after spinal surgery were identified. The aetiology comprised surgery for herniated intervertebral disc in 5 (4 performed by a single surgeon), spinal stenosis surgery in 4, and postoperative lumbar epidural haematoma in 2 patients (each performed by a different surgeon). Proportion of spinal surgeries with this complication varied from 0 to 6.6‰ in different centres. Patients with iatrogenic cauda equina lesion were significantly older (p < 0.001), and reported more severe urinary, but similar bowel and sexual symptoms compared to other patients in the series. In conclusion the study identified spinal surgery as the cause of approximately 15% of cauda equina lesions. More than a third of lesions developed after procedures performed by a single surgeon. Most of the remaining lesions could probably be avoided by better surgical technique (e.g. the use of a high-speed drill instead of a Kerrison rongeur in patients with severe spinal stenosis), or prevented by closer postoperative monitoring (e.g. in patients with postoperative lumbar epidural haematoma).
Cauda equina; Disc herniation; Spinal stenosis; Spinal surgery; Sacral
Intradural lumbar disc herniation is a rare pathological entity. The pathogenesis of intradural lumbar disc herniation is not known clearly. Intradural disc herniations usually occurred at the L4-L5 levels but have also been reported at other levels. However, intradural disc herniation at L5-S1 is quite rare. There are approximately nine reports in the English literature of intraradicular disc herniation at L5-S1. We described a 61-yr-old man with suspected intradural mass at the level of L5-S1 space. The patient presented with pain in the lower back and both lower legs for 4 months and a sudden exacerbation of the symptoms for 3 days. Gadolinium-enhanced magnetic resonance imaging (MRI) demonstrated a large disc herniation at the L5-S1 level with an intradural component. L5 and S1 laminectomy was performed, and dura was swollen and immobile. Subsequent durotomy was performed and an intradural disc fragment was removed. The patient had full recovery in 3 months. Intradural lumbar disc herniation must be considered in the differential diagnosis of mass lesions in the spinal canal. Contrast-enhanced MRI scans are useful to differentiate a herniated disc from a disc space infection or tumor.
Intervertebral Disk Displacement; Spinal Cord Neoplasms; Intradural Disc Herniation; L5-S1; Magnetic Resonance Imaging
To report a case of Cauda Equina syndrome with the completion of the paralysis after the reduction of a L4L5 dislocation due to a herniated disc. Although several articles have described a post-traumatic disc herniation in the cervical spinal canal, this is not well known in the lumbar region. A 30-year-old man was admitted to the emergency room with blunt trauma to the chest and abdomen with multiple contusions plus a dislocation of L4-L5 with an incomplete neurological injury. After an emergency open reduction and instrumentation of the dislocation, the patient developed a complete cauda equina syndrome that has resulted from an additional compression of the dural sac by a herniated disc. In a dislocation of the lumbar spine, MRI study is mandatory to check the state of the spinal canal prior to surgical reduction. A posterior approach is sufficient for reduction of the vertebral displacement, however an intra-canal exploration for bony or disc material should be systematically done.
Cauda equine; Herniated disc; Lumbar dislocation; MRI; Reduction
Intradural lumbar disc herniation is a rare complication of disc disease. The reason for the tearing of the dura matter by a herniated disc is not clearly known. Intradural disc herniations usually occur at the disc levels and are often seen at L4–L5 level but have also been reported at other intervertebral disc levels. However, intradural disc herniation at mid-vertebral levels is rare in the literature and mimics an intradural extramedullary spinal tumor lesion in radiological evaluation. Although magnetic resonance imaging (MRI) with gadolinium is useful in the diagnosis of this condition, preoperative correct diagnosis is usually difficult and the definitive diagnosis must be made during surgery. We describe here a 50-year-old female patient who presented with pain in the lower back for 6 months and a sudden exacerbation of the pain that spread to the left leg as well as numbness in both legs for 2 weeks. MRI demonstrated an intradural mass at the level of L5. Laminectomy was performed, and subsequently durotomy was also performed. An intradural disc fragment was found and completely removed. The patient recovered fully in 3 months. Intradural lumbar disc herniation must be considered in the differential diagnosis of mass lesions in the spinal canal.
Intervertebral disc herniation; Intradural disc herniation; Intraspinal tumor; L5
Low back pain is common during pregnancy. However, the prevalence of symtomatic lumbar disc herniation is rare, and cauda equina syndrome due to disc herniation during pregnancy is even rarer. We report a rare case of lumbar disc herniation causing cauda equina syndrome during third trimester of pregnancy which successfully treated by endoscopic discectomy. This case shows that endoscopic discectomy can be the treatment option for the lumbar disc herniation during pregnancy.
Lumbar disc herniation; Pregnancy; Endoscopic discectomy
Intradural extramedullary epidermoid (EC) cysts are uncommon (0,2–1%). Acquired tumors appear more frequently as a late complication of lumbar punctures (40%). The authors present three cases of epidermoid cysts of the cauda equina which were surgically treated in their department during the past five years. All three had suffered lumbar punctures for rachianesthesia 6–9 years prior to their presentation. The patients' ages ranged between 19 and 31. Surgical treatment was deemed necessary because of the space–occupying nature of this slow–growing lesion, and this indication was supported by the MRI findings. Two–level laminectomy and microsurgical total tumor ablation were performed in all three cases. There were no postoperative complications.
lumbar punctures; laminectomy; microsurgery
Existing studies on micro-endoscopic lumbar discectomy report similar outcomes to those of open and microdiscectomy and conflicting results on complications. We designed a randomised controlled trial to investigate the hypothesis of different outcomes and complications obtainable with the three techniques. 240 patients aged 18–65 years affected by posterior lumbar disc herniation and symptoms lasting over 6 weeks of conservative management were randomised to micro-endoscopic (group 1), micro (group 2) or open (group 3) discectomy. Exclusion criteria were less than 6 weeks of pain duration, cauda equina compromise, foraminal or extra-foraminal herniations, spinal stenosis, malignancy, previous spinal surgery, spinal deformity, concurrent infection and rheumatic disease. Surgery and follow-up were made at a single Institution. A biomedical researcher independently collected and reviewed the data. ODI, back and leg VAS and SF-36 were the outcome measures used preoperatively, postoperatively and at 6-, 12- and 24-month follow-up. 212/240 (91%) patients completed the 24-month follow-up period. VAS back and leg, ODI and SF36 scores showed clinically and statistically significant improvements within groups without significant difference among groups throughout follow-up. Dural tears, root injuries and recurrent herniations were significantly more common in group 1. Wound infections were similar in group 2 and 3, but did not affect patients in group 1. Overall costs were significantly higher in group 1 and lower in group 3. In conclusion, outcome measures are equivalent 2 years following lumbar discectomy with micro-endoscopy, microscopy or open technique, but severe complications are more likely and costs higher with micro-endoscopy.
Lumbar disc herniation; Discectomy; Microdiscectomy; Micro-endoscopic discectomy
We report a case of lumbar intradural extramedullary lesion in an 11-year-old boy who presented with cauda equina syndrome and acute bladder disturbance. He underwent emergency surgical resection of the lesion, which was proved to be a lymphoma by histopathology and immunohistochemistry. He has improved neurologically and after 1 year, he is leading a normal life with near normal neurological functions. This is the second case of primary spinal intradural extramedullary lymphoma. This is the first such case in the pediatric age group and causing cauda equina syndrome. We describe the characteristics of such tumors along with pathogenesis and management.
Cauda equina syndrome; chemoradiation; intradural extramedullary tumors; primary spinal lymphoma
Herniated disc, while not the most common cause of low back pain, is the most common reason for surgery to relieve back pain. An alternative to surgery when sciatic pain is the result of disc herniation is chemonucleolysis with chymopapain. Since this enzyme is effective only in very specific circumstances, proper patient selection is crucial. Five criteria for selection are presented, emphasizing that since chemonucleolysis is not conservative treatment, it should be reserved for patients whose pain is unrelieved by conservative methods. There are several important contraindications to chemonucleolysis: allergy to chymopapain, risk of injury to the cauda equina, disc lesions at cord levels, pregnancy, patient's age (not recommended for adolescents) and sequestrated disc. Technique is exacting and should be limited to surgeons with the opportunity for concentrated experience.
Herniated disc; chemonucleolysis; chymopapain
There is no validated gold-standard diagnostic support tool for LSS, and therefore an accurate diagnosis depends on clinical assessment. Assessment of the diagnostic value of the history of the patient requires an evaluation of the differences and overlap of symptoms of the radicular and cauda equina types; however, no tool is available for evaluation of the LSS category. We attempted to develop a self-administered, self-reported history questionnaire as a diagnostic support tool for LSS using a clinical epidemiological approach. The aim of the present study was to use this tool to assess the diagnostic value of the history of the patient for categorization of LSS.
The initial derivation study included 137 patients with LSS and 97 with lumbar disc herniation who successfully recovered following surgical treatment. The LSS patients were categorized into radicular and cauda equina types based on history, physical examinations, and MRI. Predictive factors for overlapping symptoms between the two types and for cauda equina symptoms in LSS were derived by univariate analysis. A self-administered, self-reported history questionnaire (SSHQ) was developed based on these findings. A prospective derivation study was then performed in a series of 115 patients with LSS who completed the SSHQ before surgery. All these patients recovered following surgical treatment. The sensitivity of the SSHQ was calculated and clinical prediction rules for LSS were developed. A validation study was subsequently performed on 250 outpatients who complained of lower back pain with or without leg symptoms. The sensitivity and specificity of the SSHQ were calculated, and the test-retest reliability over two weeks was investigated in 217 patients whose symptoms remained unchanged.
The key predictive factors for overlapping symptoms between the two categories of LSS were age > 50, lower-extremity pain or numbness, increased pain when walking, increased pain when standing, and relief of symptoms on bending forward (odds ratio ≥ 2, p < 0.05). The key predictive factors for cauda equina type symptoms were numbness around the buttocks, walking almost causes urination, a burning sensation around the buttocks, numbness in the soles of both feet, numbness in both legs, and numbness without pain (odds ratio ≥ 2, p < 0.05). The sensitivity and specificity of the SSHQ were 84% and 78%, respectively, in the validation data set. The area under the receiver operating characteristic curve was 0.797 in the derivation set and 0.782 in the validation data set. In the test-retest analysis, the intraclass correlation coefficient for the first and second tests was 85%.
A new self-administered, self-reported history questionnaire was developed successfully as a diagnostic support tool for LSS.
In animal models of degenerative lumbar disease, inducible nitric oxide synthase (iNOS) is expressed in macrophages and Schwann cells following compression of the cauda equina. We previously reported that NO metabolites (nitrite plus nitrate: [NOx]) in the cerebrospinal fluid (CSF) correlate with postoperative pain relief in patients with degenerative lumbar disease and with neurologic recovery rate postoperatively or after conservative treatment in patients with spinal cord injury. The objective of the present study was to examine the relationship between [NOx] and neurologic severity, and recovery in degenerative cervical and lumbar diseases. Two hundred fifty-seven cases, including 85 patients with cervical compression myelopathy (CCM), 25 with cervical disc herniation (CDH), 70 with lumbar canal stenosis (LCS), and 77 with lumbar disc herniation (LDH), were examined. The CSF [NOx] was measured using the Griess method. Severity of neurologic impairment and clinical recovery was assessed using the Japanese Orthopedic Association score and Hirabayashi’s method. [NOx] in CCM and LCS, but not CDH and LDH groups, was significantly higher than that in controls, and correlated with postoperative recovery rates, but not with preoperative neurologic severity. [NOx] significantly correlated with neurologic recovery following surgery for CCM and LCS.
Nitric oxide; Degenerative cervical diseases; Degenerative lumbar diseases; Cerebrospinal fluid; Neurologic severity; Neurologic recovery
Ependymomas presenting with intratumoural and/or subarachnoid haemorrhages are seen rarely. These haemorrhages are mostly due to anticoagulation, epidural analgesia or pregnancy. A 62-year-old male farmer with cauda equina syndrome after a work-related trauma is presented. He was admitted to our hospital with paraparesis, faecal incontinance and sensory loss below the level of the lumbar-2 dermatome. Magnetic resonance imaging of the spine displayed an intradural mass lesion at the level of the first lumbar vertebrae. The lesion was excised totally via dorsal midline approach. Histopathologic examination revealed grade-3 ependymoma with intratumoural haemorrhage. The patient’s symptoms were relieved completely on postoperative day 7. The patient was given information about periodical examination for recurrence and discharged on the third postoperative week. Asymptomatic spinal lesions should be considered for operation whenever detected because of unpredicted complications.
Cauda equina syndrome; Ependymoma; Filum terminale; Intratumoural haemorrhage; Spinal cord tumours; Spinal trauma
Posterior epidural migration (PEM) of free disc fragments is rare, and reported PEM patients usually presented with radicular signs. An uncommon case involving a patient with cauda equina syndrome due to PEM of a lumbar disc fragment is reported with a review of the literature. The patient described in this report presented with an acute cauda equina syndrome resulting from disc fragment migration at the L3–L4 level that occurred after traction therapy for his lower back pain. The radiological characteristics of the disc fragment were the posterior epidural location and the ring enhancement. A fenestration was performed and histologically confirmed sequestered disc material was removed. An early postoperative examination revealed that motor, sensory, urological, and sexual functions had been recovered. At late follow-up, the patient was doing well after 18 months. Sequestered disc fragments may occasionally migrate to the posterior epidural space of the dural sac. Definite diagnosis of posteriorly located disc fragments is difficult because the radiological images of disc fragments may mimic those of other more common posterior epidural lesions.
Cauda equina syndrome Disc migration Lumbar disc Sequestered disc
Intraradicular lumbar disc herniation is a rare complication of disc disease that is generally diagnosed only during surgery. The mechanism for herniated disc penetration into the intradural space is not known with certainty, but adhesion between the radicular dura and the posterior longitudinal ligament was suggested as the most important condition. The authors report the first case of an intraradicular lumbar disc herniation without subdural penetration; the disc hernia was lodged between the two radicular dura layers. The patient, a 34-year-old soldier, was admitted with a 12-month history of low back pain and episodic left sciatica. Neurologic examination showed a positive straight leg raising test on the left side without sensory, motor or sphincter disturbances. Spinal CT scan and MRI exploration revealed a left posterolateral osteophyte formation at the L5–S1 level with an irregular large disc herniation, which migrated superiorly. An intradural extension was suspected. A left L5 hemilaminectomy and S1 foraminotomy were performed. The exploration revealed a large fragment of disc material located between the inner and outer layers of the left S1 radicular dura. The mass was extirpated without cerebrospinal fluid outflow. The postoperative course was uneventful. Radicular interdural lumbar disc herniation should be suspected when a swollen, hard and immobile nerve root is present intraoperatively.
Intradural disc herniation; Intraradicular lumbar disc; Magnetic resonance imaging; Spinal nerve root compression
The purpose of this case report is to describe a case of metastatic non-Hodgkin lymphoma in the lumbar spine presenting as lumbar radiculopathy.
A 46-year-old man sought care from his doctor of chiropractic for low back pain and right leg radiculopathy. The patient was referred for a magnetic resonance imaging (MRI) scan to evaluate for a suspected disk herniation. The MRI scan revealed 2 lumbar pathologic compression fractures with cauda equina compression, and MRI short tau inversion recovery (STIR) sagittal image of the lumbar spine showed high signal in T12 and S2.
Intervention and Outcome
The patient was referred for an immediate consultation with his medical physician with the preliminary diagnosis of metastatic bone lesions or primary bone lesions of unknown etiology. The patient underwent bone biopsy, computed tomography, and positron emission tomography scanning and was diagnosed with small cell non-Hodgkin lymphoma with osseous metastasis. The patient underwent chemo- and radiation therapy, and the lymphoma is now in remission 18 months later.
This case describes the presentation of metastatic non-Hodgkin lymphoma as a possible contributing cause in a patient presenting with lumbar radiculopathy, a common musculoskeletal condition. As well, this case highlights the importance of STIR sequences as part of a routine lumbar spine MRI examination. Without the STIR sequences, the additional deposits in T12 and S1 would not have been readily appreciated. Although metastatic non-Hodgkin lymphoma of the spine is rare, it should be remembered in the differential diagnoses.
Non-Hodgkin lymphoma; Spine; Radiculopathy; Magnetic resonance imaging; Metastasis; Chiropractic
Intradural extra-arachnoid lumbar disc herniation is a rare disease. Few MRI findings have been reported. We experienced an intradural extra-arachnoid lumbar disc herniation. We reviewed the preoperative MRI findings. Lumbar spine T2-weighted sagittal MRI showed that one line of the ventral dura was divided into two by a disc herniation. We speculated that the two lines comprised the dura and arachnoid and that a disc herniation existed between them. We believe that division of the ventral dural line on T2-weighted sagittal images is a characteristic finding of intradural extra-arachnoid lumbar disc herniation. The division of ventral dural line seemed to be a “Y,” and, thus, we called it the “Y sign.” The “Y sign” may be useful for diagnosing intradural extra-arachnoid lumbar disc herniation.
The authors report a rare case of primary spinal ependymomatosis in a young adult man. Multiple primary ependymomatous lesions were seen on magnetic resonance imaging and no anaplasia was identified on the surgical-pathological analysis. The aetio-pathological mechanism and surgical significance of this rare occurrence is discussed.
A 26-year-old man of Polish origin presented with a ten-day history of pain in the left leg and lower back. This was followed by difficulty in urinating and a decrease in sensation in both legs. Examination revealed pyramidal signs and mild weakness in both lower limbs. He had early sphincter involvement requiring catheterization. Magnetic resonance imaging of the brain was normal. However, that of the spinal cord revealed multiple intradural spinal lesions, both intra- and extramedullary, extending from the cervical cord down to the cauda equina roots. T12-L1 laminectomy was performed. Multiple intradural, extra- and intra-medullary tumors were seen. After the operation, the patient deteriorated with a sensory level at T4. Post-operative cranio-spinal radiotherapy was administered but there was no clinical improvement in the lower limbs.
Primary spinal ependymomatosis is a rare phenomenon involving multiple spinal segments in the absence of a primary intracranial tumor. Radical excision is unrealistic in this condition. Biopsy followed by radiotherapy is the preferred method of treatment.
Cauda equina syndrome (CES) is a rare condition with a disproportionately high medico-legal profile. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration. Review of the literature indicates that around 50–70% of patients have urinary retention (CES-R) on presentation with 30–50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression by a suitably experienced surgeon. Every effort should be made to avoid CES-I with its more favourable prognosis becoming CES-R while under medical supervision either before or after admission to hospital. The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage. A full explanation and consent procedure prior to surgery is essential in order to reduce the likelihood of misunderstanding and litigation in the event of a persistent neurological deficit.
Cauda equina syndrome; Central disc prolapse; Bilateral sciatica; Urinary retention; Perineal hypoaesthesia; Sexual dysfunction
To determine the level of brain-derived neurotrophic factor (BDNF) in experimental dog model of severe acute cauda equina syndrome, which was induced by multiple cauda equina constrictions throughout the entire lumbar (L), sacral (S) and coccygeal (Co) spinal cord and their central processes of the dorsal root ganglia neurons. Adult male mongrel dogs were randomly divided into 2 groups. The experiment group (n=4) was subjected to multiple cauda equina constrictions. The control group (n=4) was subjected to cauda equina exposure without constrictions. Level of BDNF in the spinal cord and the dorsal root ganglion cells (L7, S1-S3) was assessed 48 hours after multiple constrictions by immunohistochemical and histopathological analyses. 48 hours after multiple constrictions of cauda equina, up-regulation of BDNF within lumbosacral (L7-S3) spinal cord and dorsal root ganglion was observed in experimental group as compared to control group. Our result suggests that BDNF might play a role in the inflammatory and neuropathic pain as a result of multiple cauda equina constrictions. Regulation of BDNF level could potentially provide a therapy for treating cauda equina syndrome.
Cauda equina syndrome (CES); dorsal root ganglion (DRG); brain-derived neurotrophic factor (BDNF); multiple cauda equina constrictions (MCEC); neurotrophic factors (NFs)
Sacral nerve stimulation (SNS) is an effective treatment for bladder and bowel dysfunction, and also has a role in the treatment of chronic pelvic pain. We report two cases of intractable pain associated with cauda equina syndrome (CES) that were treated successfully by SNS. The first patient suffered from intractable pelvic pain with urinary incontinence and fecal incontinence after surgery for a herniated lumbar disc. The second patient underwent surgery for treatment of a burst fracture and developed intractable pelvic area pain, right leg pain, excessive urinary frequency, urinary incontinence, voiding difficulty and constipation one year after surgery. A SNS trial was performed on both patients. Both patients' pain was significantly improved and urinary symptoms were much relieved. Neuromodulation of the sacral nerves is an effective treatment for idiopathic urinary frequency, urgency, and urge incontinence. Sacral neuromodulation has also been used to control various forms of pelvic pain. Although the mechanism of action of neuromodulation remains unexplained, numerous clinical success reports suggest that it is a therapy with efficacy and durability. From the results of our research, we believe that SNS can be a safe and effective option for the treatment of intractable pelvic pain with incomplete CES.
Sacral Plexus; Neuromodulator; Pain; Cauda Equina