Surgical treatment of progressive cauda equina compression c
A 38-year-old man experienced sudden onset of lower back pain when he bent down to pick up a newspaper off the floor. There was no history of trauma, cardiovascular disease, and bleeding disorders as well as no experience with drugs. The lower back pain worsened, and bilateral leg pain developed within 3 days. The subject received a medical examination and a magnetic resonance imaging (MRI) scan of the lumbar spine at a local hospital. MRI images revealed a large subdural hematoma, extending from L1 to S1 in the sagittal view and presenting as hyperintensities on T1 weighted sequences and hypointensities to isointensities on T2 weighted sequences.

A conservative treatment plan was decided upon at a local hospital because there were no severe neurological deficits. However, the symptoms worsened progressively with lower extremity muscle weakness, gait disturbance, and numbness in the saddle area 15 days after onset. Therefore, the subject was transferred to our center for further examination and management.

A neurological examination demonstrated paresthesia and pain below the L4 dermatome and motor weakness at grade 4 on the right lower limb and grade 3 on the left lower limb. The bilateral Achilles’ tendon reflex decreased, and the straight-leg-raising test was positive for both lower limbs. There was no evidence of bowel and bladder disturbances, and no pathological reflexes were identified. Laboratory tests revealed an acceptable platelet count and normal coagulation. A repeated MRI scan of the lumbar spine revealed an increase in the size of the subdural hematoma from L4 to S1 in the sagittal views, and the cauda equina was dorsally compressed in the axial views. Furthermore, there was a change in the signal intensity of the subdural hematoma, which presented as hyperintensities on both T1-weighted and fat-suppressed T2-weighted sequences.

Subdural evacuation of the hematoma was performed immediately to improve the neurological symptoms. After bilateral L5-S1 laminectomy, the ligamentum flavum sustained hypertrophy and turned brown, and it was resected intraoperatively. A pathological examination showed degeneration and formation of a new hematoma within the ligament. The dura mater was tough and discolored. After opening the dura with a longitudinal midline incision, dark brown blood drained spontaneously. The region was irrigated with saline until the cerebrospinal fluid was clear and the nerve roots were visible through the intact arachnoid membrane. There was no evidence of a vascular abnormality and no bleeding from the subarachnoid space. After closing the dura with running lock sutures, its pulsatile motion was restored

Postoperatively, the lower limb pain improved immediately. An MRI revealed complete drainage of the chronic SDH. The patient was discharged 1 week after surgery. At the 6-month follow-up, the pain and numbness of the lower limb pain disappeared, and the muscle strength of both legs recovered completely with normal gait.

Source: Clinical Case Report

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