Cauda equina syndrome with surgical intervention in pregnancy during the periviable period

Abstract

Introduction: Cauda equina syndrome (CES) following lumbar disc herniation is exceedingly rare in pregnancy and there is limited literature outlining management of CES in pregnancy. There is further limited data addressing the management of periviable pregnancies complicated by CES.

Case presentation: A 38-year-old female at 22 weeks gestation presented with worsening lower back pain radiating to the right posterior lower extremity. She was initially managed with conservative therapy, but re-presented with worsening neurologic symptoms, including fasciculations and perineal numbness. Magnetic resonance imaging showed a large herniated disc at L4-5, and given concern for CES, she underwent emergent decompression surgery, which was complicated by a superficial wound dehiscence. She ultimately carried her pregnancy to term and had a cesarean delivery. The patient's residual neurologic symptoms continued to improve with physical therapy throughout the postpartum period.

Discussion: Cauda equina syndrome is a rare spinal condition with potentially devastating outcomes if not managed promptly. Diagnosis and management of CES in pregnancy is the same as in non-pregnant patients, however, standardization of patient positioning for surgery, surgical approach, anesthetic use, and fetal considerations is lacking. A multidisciplinary approach is critical, especially at periviable gestational ages of pregnancy. Our case and review of the literature demonstrates that patients in the second trimester can be managed surgically with prone positioning, intermittent fetal monitoring, and continued management of the pregnancy remains unchanged. Given the rarity of these cases, there is a need for a consensus on management and continued care in pregnant patients with CES.