Mugge Luke, Caras Andrew, Miller William, Buehler Mark, Medhkour Azedine
Neurological Surgery, Inova Neuroscience and Spine Institute, Falls Church, USA.
Neurological Surgery, The University of Toledo Medical Center, Toledo, USA.
Cureus. 2019 May 11;11(5):e4645. doi: 10.7759/cureus.4645.
Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation, this is an unusual presentation with epidural disc extrusion. We present a very rare case of Cauda Equina syndrome, resulting from an epidural disc extrusion at L3-L4 level. Patient care and progress notes were reviewed along with pre-, post-, and intra-operative radiological imaging. Here, a 19-year-old male with a past medical history of type I diabetes mellitus, fell asleep on a chair at home in an unusual position and was unable to walk on awakening. The patient developed progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction. In addition, he experienced paresthesia and severe lower back pain unresponsive to steroids. Pre-operative magnetic resonance imaging (MRI) demonstrated a herniated disk epidurally with disc extrusion and mass effect and compression at the L3-L4 level, wrapping around the posterior aspect of the dura. A diagnosis of cauda equina syndrome was made and surgical decompression was performed. Using microsurgical technique and fluoroscopic guidance, a bilateral laminectomy of L3 was achieved with bilateral partial laminectomy of L4, with bilateral foraminotomy of L4. After removal of the lamina, a mass was immediately visualized in the posterior epidural space. Further dissection of the substance and following it posteriorly, identified the mass as a portion of the extruded disc. Post-operatively, the patient experienced rapid recovery. In conclusion, this case demonstrates that a disc extrusion can occur within the epidural space and can cause cauda equina syndrome. As this presentation is unusual, surgeons must be aware that they may encounter disc mass in unexpected locations, in a clinically delayed setting, long after the initial onset of symptoms.
硬膜外椎间盘突出极为罕见，可能导致马尾综合征。这是一种外科急症，需要迅速减压。虽然马尾综合征通常由椎间盘突出引起，但硬膜外椎间盘突出导致该综合征的情况并不常见。我们报告一例非常罕见的因L3-L4水平硬膜外椎间盘突出导致的马尾综合征病例。回顾了患者的护理及病情记录，以及术前、术后和术中的影像学检查。该患者为19岁男性，有I型糖尿病病史，在家中以不寻常姿势坐在椅子上入睡，醒来后无法行走。患者出现进行性神经功能缺损，包括双侧足下垂以及肠道和膀胱功能障碍。此外，他还感到感觉异常和严重的下背部疼痛，对类固醇治疗无反应。术前磁共振成像（MRI）显示硬膜外有椎间盘突出，伴有椎间盘挤出、占位效应以及L3-L4水平的压迫，环绕硬脊膜后侧。诊断为马尾综合征并进行了手术减压。采用显微外科技术并在荧光镜引导下，完成了L3双侧椎板切除术及L4双侧部分椎板切除术，并进行了L4双侧椎间孔切开术。去除椎板后，立即在后硬膜外间隙看到一个肿物。进一步解剖该肿物并追踪其后方，确定肿物为挤出椎间盘的一部分。术后，患者恢复迅速。总之，该病例表明椎间盘可在硬膜外间隙突出并导致马尾综合征。由于这种表现不常见，外科医生必须意识到，在临床延迟的情况下，即在症状最初出现很长时间后，他们可能会在意外位置遇到椎间盘肿物。
