International Journal of Surgery Case Reports 114 (2024) 109188

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International Journal of Surgery Case Reports

Case report

Recovery with posterior decompression and dural suturing in a patient with

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: This report investigates Cauda Equina Syndrome (CES), a critical neurological condition from
Cauda equine syndrome lumbar and sacral nerve root compression that arises from trauma, such as unstable burst fractures leading to
Lumbar burst fracture interlaminar entrapment. This study highlights the effective management and recovery of a young woman with
Posterior decompression
CES following a traumatic fall, offering new insights into the condition's treatment and recovery process.
Rehabilitation
Case presentation: A 24-year-old female experienced severe lower back pain, bilateral lower limb weakness,
Neurologic recovery
saddle anesthesia, and bladder dysfunction after a 3-m fall. The neurological assessment showed reduced
sensation and motor function in the lower extremities. Diagnostic imaging revealed an unstable L2 burst fracture
with cauda equina entrapment. She underwent emergency posterior decompression and dural repair, followed by
a tailored rehabilitation program, which is a novel aspect of this study.
Discussion: This report underscores the critical need for immediate surgical intervention in CES to avert lasting
neurological damage. The case represents the significance of early decompression for improving prognosis and
explores the complexities of managing CES with unstable spinal fractures and dural tears. It demonstrates the
challenges in surgical intervention and postoperative rehabilitation, offering a new perspective on the integrative
approach to treatment.
Conclusion: This case exemplifies the imperative CES management post-spinal trauma. Despite severe initial
deficits, an innovative multidisciplinary approach involving surgery and early rehabilitation resulted in
remarkable functional recovery. This study contributes to a new understanding of CES management in acute
trauma settings and calls for further research to advance treatment protocols and enhance predictive outcomes.

1. Introduction patient outcomes [2,6]. The stakes are high, the window for reversing
neurological damage is narrow, and the timing of surgery is a critical
Cauda equina syndrome (CES) is a critical orthopedic emergency factor affecting prognosis. A delay in decompression can lead to irre­
characterized by the sudden impairment of the lumbar and sacral nerve versible deficits, whereas timely intervention can significantly enhance
roots. This condition manifests as a range of symptoms and can be fatal. the likelihood of recovery [6,7]. In South Korea, traumatic spinal cord
The symptoms include lower extremity paralysis, sensory deficits in the injuries, including cases that may lead to Cauda Equina Syndrome (CES),
“saddle” area, and dysfunction of bladder and bowel control. CES is have shown evolving trends over the last 30 years. An increase in the
typically caused by conditions that lead to acute compression of nerve average age of individuals suffering from these injuries, particularly due
roots, such as herniated discs, tumors, infections, and traumatic spinal to falls among the elderly, has been noted. However, specific data on the
injuries [1–5]. prevalence and incidence of CES caused by spinal trauma are limited, as
CES resulting from traumatic spinal injury presents unique chal­ comprehensive health registries or dedicated spinal injury databases are
lenges. The intricate anatomy of the spine and sensitive nature of spinal not extensively established in the country [8]. This case report describes
cord injuries require prompt and precise intervention to optimize the patient's clinical presentation, diagnosis, treatment, and subsequent

Abbreviations: CES, cauda equina syndrome; MRI, magnetic resonance imaging; TLSO, thoracic-lumbar-sacral orthosis; CSF, cerebrospinal fluid.
E-mail address: [email protected].

https://doi.org/10.1016/j.ijscr.2023.109188
Received 17 November 2023; Received in revised form 15 December 2023; Accepted 18 December 2023
Available online 22 December 2023
2210-2612/© 2023 The Author. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
D.-J. Lim International Journal of Surgery Case Reports 114 (2024) 109188

recovery. We also discuss the critical aspects of CES management, such rehabilitation program. The program included physical therapy to
as prompt diagnosis, surgical techniques, and multidisciplinary post­ strengthen the paraspinal and lower-limb muscles, improve proprio­
operative care. This case report has been prepared following the SCARE ception, and facilitate neural recovery. Towards the end of the third
2023 Standards [9]. month, the patient exhibited improvements in motor function, as evi­
denced by her ability to perform assisted ambulation.
2. Presentation of case At the six-month follow-up, the patient had made remarkable prog­
ress, transitioning from walking to independent ambulation. She re­
A 24-year-old female patient was brought to the emergency depart­ ported reduced pain and regained substantial control over her lower
ment after falling from a height of 3 m. Upon arrival, the patient was limb movements. The rehabilitation process was further complemented
fully conscious with stable vital signs. However, she reported severe by neurogenic bladder management strategies, including scheduled
lower back pain with complete bilateral lower limb paraplegia and was catheterization and pelvic floor exercises, which were tapered as her
unable to void, indicating potential cauda equina syndrome (CES). The condition improved.
initial physical examination revealed saddle anesthesia and significant Two years after the injury, the patient's condition continued to
bilateral neuromotor deficits in the lower extremities. Her both tibialis improve. The patient could ambulate freely without a walker or cane.
anterior muscle, extensor hallucis longus muscle, and flexor hallucis Her muscle strength in both lower extremities was nearly Grade 4–5. She
longus showed motor power of grades 0, respectively. Urinary retention reported a significant decrease in the frequency of incontinence episodes
was confirmed, necessitating immediate catheterization. and a return to normal bowel function, reflecting recovery from bladder
Assessments using computed tomography and magnetic resonance and bowel dysfunction that characterized her initial CES presentation.
imaging (MRI) identified an unstable L2 burst fracture with retropulsion This functional recovery highlights the plasticity of the nervous system,
bone fragments encroaching on the spinal canal and compressing the the potential for long-term recuperation following severe traumatic
cauda equina. The MRI further demonstrated the splaying of nerve roots injury, and diligent postoperative management.
around the fractured lamina, confirming CES caused by interlaminar
entrapment (Fig. 1). 3. Discussion
Given the urgency, the patient underwent emergency surgery, which
entailed posterior decompression to release the entrapped nerve roots, CES is a critical emergency requiring immediate recognition and
stabilization with pedicle screws and rods, and meticulous dural repair intervention to prevent permanent neurological deficits [2,10]. In this
to address the tear (Figs. 2 and 3). The surgery was performed to relieve case, the urgency for surgical intervention was underscored by the
mechanical compression and restore the integrity of the dura mater to diagnosis of CES, confirmed through MRI, which evidenced cauda
prevent cerebrospinal fluid leakage and the risk of subsequent menin­ equina entrapment alongside an unstable vertebral fracture. This situ­
geal complications. ation is especially dangerous because of the involvement of multiple
Postoperatively, the patient was fitted with a thoracic-lumbar-sacral nerve roots governing lower limb and pelvic organ function [11]. The
orthosis (TLSO) brace to support the spine during the healing process prognosis of CES depends heavily on the timeliness of the surgical
and minimize movement-induced strain at the surgical site. The patient treatment, with earlier interventions typically resulting in better out­
wore the TLSO brace for three months while engaging in a structured comes, especially in traumatic cases [4,12,13]. Specific case details and

Fig. 1. A) L2 posterior subluxation and kyphotic deformity, as evidenced in preoperative X-ray and MRI. B) Splayed nerve roots are compressed and entrapped
against the fractured lamina (Arrows). C) L2 burst fracture with fragments and lamina fracture impinging in the spinal canal in 3D CT.

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D.-J. Lim International Journal of Surgery Case Reports 114 (2024) 109188

Fig. 2. A) Meticulous lamina removed after instrumental fixation and exposed dural tear. B) The exposed cauda quina was explored, and the dural tear margin
(Arrowheads) was confirmed. C) Dura was repaired using continuous sutures (Nylon 7–0, yellow arrows). (For interpretation of the references to colour in this figure
legend, the reader is referred to the web version of this article.)

Fig. 3. A) Decompression (yellow dot line) and Posterior fusion employing a pedicle screw fixation at T12–L3 levels with bone graft. B) Postoperative one-month
follow-up findings. C) Postoperative three-month follow-up findings. Stop wearing TLSO after this time. D) Postoperative one-year follow-up findings. E) Post­
operative two-year follow-up findings. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

a comprehensive review of existing reports on CES reinforce this. sharp edges of the broken lamina during the injury [14]. When the axial
A possible explanation for posterior dural tears in cases of vertical force decreases, the fractured lamina pieces return to their original po­
greenstick fracture of the lamina is that the dural sac is pierced by the sition, possibly trapping the dural sac and nerve roots [14], which

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D.-J. Lim International Journal of Surgery Case Reports 114 (2024) 109188

worsens the neurologic condition [15,16]. written consent is available for review by the Editor-in-Chief of this
A greenstick fracture is an incomplete fracture that occurs when the journal.
bone bends and breaks only on the convex side. In some cases, a
greenstick fracture of the lamina can cause dural tears or cauda equina Ethical approval
entrapment, leading to neurological deficits [13,16,17]. The cauda
equina is a bundle of nerve roots extending from the spinal cord's end This case study was approved by the Institutional Review Board of
and occupying the spinal canal's lower part. It can be pinched by bony Sanggye Paik Hospital (SGPAIK 2023-10-012).
fragments or disc materials displaced into the spinal canal during a burst The approved date is November 9, 2023.
fracture. The filum terminale is a thin tissue strand that connects the
cauda equina to the coccyx. It can also be injured during spinal surgery, Funding
mainly if the lamina is not completely fractured and must be removed
[18]. This research did not receive any specific grant from funding
The clinical imperative for rapid decompression to alleviate neuro­ agencies in the public, commercial, or not-for-profit sectors.
logical impairment in CES is well established. Studies have consistently
demonstrated that the duration of nerve compression is inversely related
Author contribution
to the recovery of motor, sensory, and autonomic functions. In this case,
surgical intervention was within the window period typically advocated
Author - study concept, design, data collection and data analysis.
for optimal outcomes, generally within 48 h of symptom onset [19]. The
writing the paper and data interpretation, data curation, investigation.
early release of cauda equina compression likely contributed to the
progressive recovery of her neurological function, as evidenced by the
Guarantor
return of independent ambulation and improvement in bladder and
bowel control over two years.
The author accepts full responsibility for the work and conduct of the
The technical aspects of CES surgery, as encountered in this case,
study, had access to the data, and controlled the decision to publish.
involve decompression, the need for stabilization, and the need to
address any incidental durotomy. Stabilization using pedicle screws and
rods in our patient provided the necessary structural support for the Research registration number
injured vertebrae, while dural sutures mitigated the risks associated
with cerebrospinal fluid (CSF) leaks, such as meningitis, pseudome­ 1. Name of the registry:
ningocele formation, and wound dehiscence [1]. Dural repair tech­ the Research Registry
niques have evolved over time, with primary sutures favored for their 2. Unique identifying number or registration ID:
efficacy in preventing CSF-related complications that can otherwise lead Researchregistry9707
to prolonged hospitalization, increased healthcare costs, and additional 3. Hyperlink to your specific registration (must be publicly accessible
surgeries. and will be checked):
Postoperative management of CES extends beyond surgical treat­
ment and involves a comprehensive rehabilitation program. Our case Remove the link for anonymity purposes
exemplifies the benefits of the early initiation of physical therapy, as
supported by several studies indicating that early mobilization and Conflict of interest statement
rehabilitation are crucial for neurological recovery. The rehabilitation
process is tailored to patient-specific needs and typically includes mus­ The author have no conflict of interests to declare.
cle strengthening, gait training, and bladder management. Gradual
restoration of the patient's motor and sensory functions and bladder and
References
bowel control demonstrates the effectiveness of this interdisciplinary
approach. [1] J. Woodfield, I. Hoeritzauer, A.A.B. Jamjoom, J. Jung, S. Lammy, S. Pronin,
Furthermore, prior reports highlight the need for extensive research Presentation., et al., Presentation, management, and outcomes of cauda equina
on the long-term outcomes of CES. Although short-term recovery is well- syndrome up to one year after surgery, using clinician and participant reporting: a
multi-Centre prospective cohort study, Lancet Reg. Health Eur. 24 (2023), 100545.
documented, the longitudinal trajectory of CES recovery lacks extensive [2] Hoeritzauer I, Paterson M, Jamjoom AAB, Srikandarajah N, Soleiman H, Poon
research. Our case contributes to the evidence suggesting that signifi­ MTC, et al. Cauda equina syndrome. Bone Joint J. 2023;105–B:1007–12.
cant long-term recovery is possible, providing a reference point for ex­ [3] O. Nasim, B. Eskander, Z. Rustam, C. Pantelias, R. Moverley, Expediting the
management of suspected cauda equina syndrome (CES) in the emergency
pected outcomes in similar traumatic cases [20]. department through clinical pathway design at a district general hospital: a quality
improvement project, Cureus 14 (2022), e32722.
4. Conclusion [4] X. Foruria, K. Ruiz de Gopegui, I. García-Sánchez, J. Moreta, U. Aguirre, Martínez-
de Los Mozos, JL., Cauda equina syndrome secondary to lumbar disc herniation:
surgical delay and its relationship with prognosis, Rev. Esp. Cir. Ortop. Traumatol.
This case report highlights the importance of timely surgical inter­ 60 (2016) 153–159.
vention in managing CES caused by a traumatic lumbar burst fracture. [5] Barker TP, Steele N, Swamy G, Cook A, Rai A, Crawford R, et al. Long-term core
outcomes in cauda equina syndrome. Bone Joint J. 2021;103–B:1464–71.
The patient's successful neurological recovery, evidenced by improved [6] A. Gardner, E. Gardner, T. Morley, Cauda equina syndrome: a review of the current
ambulation and autonomic function two years post-surgery, underscores clinical and medico-legal position, Eur. Spine J. 20 (2011) 690–697.
the effectiveness of prompt, comprehensive treatment and the role of [7] M.J. Shin, W. Kim, S.K. Baik, S.Y. Kim, S.N. Kim, Cauda equina syndrome caused by
spinal dural arteriovenous fistula, Ann. Rehabil. Med. 35 (2011) 928–933.
multidisciplinary care in complex spinal injuries. This case highlights
[8] B.S. Lee, O. Kim, D. Ham, Epidemiological changes in traumatic spinal cord injuries
the need for further research to refine treatment protocols and to un­ for the last 30 years (1990–2019) in South Korea, Spinal Cord 60 (2022) 612–617.
derstand recovery outcomes in CES better, ultimately improving patient [9] C. Sohrabi, G. Mathew, N. Maria, A. Kerwan, T. Franchi, R.A. Agha, The SCARE
care for orthopedic trauma. 2023 guideline: updating consensus surgical CAse REport (SCARE) guidelines, Int.
J. Surg. Lond. Engl. 109 (2023) 1136.
[10] D. Metcalfe, I. Hoeritzauer, M. Angus, A. Novak, M. Hutton, J. Woodfield,
Consent Diagnosis of cauda equina syndrome in the emergency department, Emerg. Med. J.
40 (2023) 787–793.
[11] I.S. Lee, H.J. Kim, J.S. Lee, S.J. Kim, Y.J. Jeong, D.K. Kim, et al., Dural tears in
Written informed consent was obtained from the patient for the spinal burst fractures: predictable MR imaging findings, AJNR Am. J. Neuroradiol.
publication of this case report and accompanying images. A copy of the 30 (2009) 142–146.

4
D.-J. Lim International Journal of Surgery Case Reports 114 (2024) 109188

[12] H. Kareem, M.H. Raza, V. Kontojannis, A. Nimer, K. Tsang, Case series of posterior [17] Denis F, Burkus JK. Diagnosis and treatment of cauda equina entrapment in the
instrumentation for repair of burst lumbar vertebral body fractures with entrapped vertical lamina fracture of lumbar burst fractures. Spine (Phila Pa 1976) 1991;16
neural elements, J. Spine Surg. 4 (2018) 374–382. (8);Suppl:S433–9.
[13] X. Shi, S. Xiang, B. Dai, Z. He, Association of the presence and its types of lamina [18] M.J. Strong, E.M. Thompson, N. Roundy, N.R. Selden, Use of lumbar laminoplasty
fractures with posterior dural tear and neurological deficits in traumatic thoracic vs. laminotomy for transection of the filum terminale does not affect early
and lumbar burst fractures, BMC Musculoskelet. Disord. 22 (2021) 300. complication rates or postoperative course, Childs Nerv. Syst. 31 (2015) 597–601.
[14] J. Pickett, B. Blumenkopf, Dural lacerations and thoracolumbar fractures, J. Spinal [19] V. Kumar, V. Baburaj, R.K. Rajnish, S.S. Dhatt, Outcomes of cauda equina
Disord. 2 (1989) 99–103. syndrome due to lumbar disc herniation after surgical management and the factors
[15] E. Skiak, A. Karakasli, A. Harb, I.S. Satoglu, O. Basci, H. Havitcioglu, The effect of affecting it: a systematic review and meta-analysis of 22 studies with 852 cases,
laminae lesion on thoraco-lumbar fracture reduction, Orthop. Traumatol. Surg. Eur. Spine J. 31 (2022) 353–363.
Res. 101 (2015) 489–494. [20] R.A. Tisot, O. Avanzi, Laminar fractures as a severity marker in burst fractures of
[16] C. Ozturk, S. Ersozlu, U. Aydinli, Importance of greenstick lamina fractures in low the thoracolumbar spine, J. Orthop. Surg. (Hong Kong) 17 (2009) 261–264.
lumbar burst fractures, Int. Orthop. 30 (2006) 295–298.