This case involves a fifty-year-old male who presented to his primary care physician with complaints of lower back pain. He was referred to an orthopedic surgery for a consultation. The surgeon recommended that the patient undergo a decompression and hemilaminotomy at L3-L4 and a discectomy at L4-L5 to relieve the pain. The physician’s surgical technique was questioned due to a surgical report that mentioned difficulty with a pituitary rongeur that may have malfunctioned during the procedure. As a result, the postoperative period was met with poor results as the patient experienced bowel and bladder incontinence, sensory and motor deficits in both lower extremities, as well as foot drop. The subsequent diagnosis by the patient’s current physician was cauda equina syndrome due to trauma.
Question(s) For Expert Witness
- 1. Is it possible that this procedure caused cauda equina syndrome and when is surgical intervention indicated to relieve the symptoms?
Expert Witness Response E-001234
Complications of spinal instrumentation have been reported to cause cases of cauda equina syndrome, including misplaced pedicle screws and laminar hooks. Continuous spinal anesthesia also has been linked to cases of cauda equina syndrome. Additionally, rare cases of cauda equina syndrome caused by epidural steroid injections, fibrin glue injection, and placement of a free-fat graft have been reported. Medical and surgical situations such as bone screw fixation, fat grafts, lumbar arthrodesis for spondylolisthesis, lumbar discectomy, intradiscal therapy, lumbar puncture forming an epidural hematoma, chiropractic manipulation, and a bolus injection of anesthetic during spinal anesthesia have been related to the development of cauda equine-like syndromes. In acute compression of the conus medullaris or cauda equina, surgical decompression becomes mandatory. The goal is to relieve the pressure on the nerves of the cauda equina by removing the compressing agent and increasing the space in the spinal canal. Traditionally, cauda equina syndrome was considered a surgical emergency, with surgical decompression considered necessary within forty-eight hours after the onset of symptoms.