脊椎手術後發生的馬尾症候群併尿滯留之病例報告

楊鎧伍1、賴韋宏1、黃大維2

嘉義基督教醫院 外科部 泌尿科1; 嘉義基督教醫院 外科部 神經外科2

Cauda equina syndrome with urinary retention as a postoperative complication of lumbar spine surgery

Kai-Wu Yang1, Wei-Hong Lai1, Da-Wei Haung2

Divisions of Urology, Department of Surgery, Chia-Yi Christian Hospital1

Divisions of Neurosurgery, Department of Surgery, Chia-Yi Christian Hospital2

Introduction:

Cauda equina syndrome (CES) refers to a group of symptoms that occur when the nerves in the cauda equina become compressed or damaged. This syndroms is well known as an indication for surgical intervention, but relatively unknown as a postoperative complication following surgery for lumbar spine disease. The timing of surgical exploration is still controversy. In this report, we present a case of CES that following the spinal surgery and the literatures of such complication will be reviewed.

Case presentation:

A 54 years old male had lumbago for about 10 years, and bilateral leg numbenss with neurogenic claudication for 3 months. An MRI demonstrated severe stenosis and disc bulging at L4-L5. The patient underwent a L4 bilateral laminotomy, L4-L5 microdiscectomy and interbody fusion with Cage and bone graft, posterior lateral fixation with pedicle screws and rods. Postoperatively, the patient showed regained strength but severe numbness of bilateral shank, radiation to planta, and perineum. When Foley catheter had been removed, he suffered from urinary retention and he also suffered from constipation. Postoperative MRI imaging suspected the occurrence of an epidural hematoma and slightly compressive stenosis at L4-L5. The patient was returned to the operating room for repeated exploration and only minimal hematoma, gelfoam and duragem at epidura space were found. The dura was loosened after removal of hematoma and gefoam. However, his perineum and shank numbness had slightly improved but still presented with urinary retention after the operation. After one-month follow-up, he had successfully removed the Foley catheter but regained only partialy perineum sensation and voiding with small caliber of urine.

Discussion:

According to literature review, the incidence of CES as a postoperative complication is rare (0.08-0.2%). Decompression of an acute disc protrusion in less than 48 hours is usually recommanded and McLaren reported on six cases of postoperative CES also had better functional recovery with early decompression. However, the timing of repeated surgery is still controversial. Except for extradural compression, vascular insufficiency also plays an important role in the etiology of postoperative CES. While some journal indicated that repeated surgery maynot be helpful, Mantu Jain had adopted conservative management in such non-compressive patient and favourable outcome were reported at the end.

Conclusion:

This case report reminds us about that CES with neurogenic bladder could be a postoperative complication following the spinal surgery. At once CES is identified, emergent image study should be done to rule out the evidence of compression of spinal cord in any case. If still presented with stenosis, repeated exploration should be done. However, theses compressive lesion maynot contributed to the patient’s symptoms, and thus a vascular insufficency might be indicated. If non-compressive postoperative cauda equina syndrome is diagnosed, conservative management in these selective group could be considered.