This 35-year-old female player presented with a short history of back pain and progressive bilateral leg symptoms. She reported first experiencing right-sided buttock discomfort while at the gym two weeks previously. She woke several days later with severe low back and right buttock pain. This evolved over 24 to 48 hours to involve severe hamstring pain, lateral lower leg pain and numbness in her right foot. At this point she noted that it was impossible to stand on her tiptoes on her right leg. Shortly before her presentation she also developed a feeling of numbness in her left heel and reported that her left ankle also felt weak.
On examination she was in obvious distress and was tearful. Her lumbar spine range of motion was relatively normal. In a seated position, she had altered sensation in the S1 dermatome of her right foot. There was 4/5 weakness of right ankle plantar flexion and right ankle eversion. Her lower limb neurological examination was otherwise normal.
An x-ray series of the lumbar spine shows that the L4-L5 and L5-S1 disc spaces are narrowed. This is further demonstrated on the MRI sequences. At L4-L5 there is a large central disc extrusion which is filling the spinal canal and compressing the cauda equina. The AP extent is 11mm, transverse 18 mm and vertical extent 15 mm. There is no foraminal narrowing and normal interlaminar joints. The other lumbar levels are normal or near normal.
This player was managed with an urgent surgical decompression and discectomy. Immediately following the procedure there was a substantial improvement in her leg pain. Her lower limb neurology had normalised when she was reviewed six weeks later. She was able to return to play four months after her surgery following a progressive rehabilitation programme.
Cauda equina syndrome occurs when the nerve roots of the cauda equina are compressed and disrupt motor and sensory function to the lower extremities and bladder. Patients classically present with an acute onset of numbness in the perianal region (saddle anaesthesia), leg pain, and bladder dysfunction. This case illustrates that a high index of suspicion is needed. While this player did not have the classic symptoms (or signs) listed here, she did have evolving and bilateral symptoms. These two features were what prompted urgent imaging. When a diagnosis of cauda equina syndrome is suspected, it is essential that a comprehensive neurological exam is completed, including an assessment of sensation in the perianal region and a rectal examination to evaluate rectal tone. Where there is clinical concern, an MRI scan should be performed to look for neurologic compression. Once diagnosed cauda equina syndrome should be considered a surgical emergency. Delays in treatment can lead to significant long-term morbidity (including permanent paralysis and impaired bladder or bowel control). Studies have shown substantially improved longer term outcomes when surgery is performed within 48 hours of the onset of symptoms.
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