Cauda Equina Syndrome Secondary to Complicated Diverticulitis
A 58-year-old woman with no past medical history presented to the emergency department with progressive lumbar back pain radiating to her left leg. The pain radiated throughout the entire left leg. She also experienced a sensation of numbness in her lower left leg and foot. These symptoms had been progressing for the past 3 weeks. She had developed a gait disorder 5 days prior to presentation, which she assigned to a lack of coordination in her left foot. She also complained of urine and bowel incontinence. There was no abdominal pain. She only mentioned having had a fever 1 day prior to these complaints. During the preceding months she had lost 11 kg of body weight.\nOn physical examination the patient appeared ill. Vital signs showed a septic profile with a body temperature of 38.8°C. Neurological examination of the lower limbs revealed decreased strength in her left leg, with a strength of Medical Research Council (MRC) 3/5 in the iliopsoas, MRC 4/5 in the tibialis anterior, and MRC 4+/5 in the gastrocnemius. Strength in the right leg was entirely normal. There was normal sensation in the saddle area and the perianal area, as well as a normal anal sphincter tone. The straight leg test showed a positive Lasègue sign on the left side. Abdominal examination showed a soft, non-tender abdomen.\nLaboratory tests showed leukocytosis and an elevated C-reactive protein level (table ). Initially, urinalysis could not be performed because the patient was unable to urinate. On catheterization, however, she had a urine retention of 1,300 ml. A chest and lumbar spine X-ray were taken, which both showed no abnormalities.\nThe patient's septic condition worsened in the emergency department with a high-grade fever (40.9°C). Antibiotic therapy was started with Amoxicillin/Clavulanate and the patient was transferred to our center's intensive care unit.\nMRI of the spinal canal showed a fistula from the sigmoid colon to a presacrally localized abscess, most likely secondary to diverticulitis (fig. ). The abscess had expanded into the spinal canal, the paravertebral soft tissue on the left side, and the erector spinae muscles on both sides. Also, there were signs of sacral osteomyelitis and diffuse meningeal staining of the conus medullaris and the cauda equina. The presence of an epidural abscess could not be confirmed (fig. ). An additional chest/abdominal CT scan showed pleural fluid on both sides. There were multiple fluid and air collections located presacrally and retroperitoneally as well as along the psoas muscle. There was air in the spinal canal and the back muscles. There were no signs of spondylodiscitis (fig. ).\nConsequently, Hartmann's procedure was performed as treatment for the diverticulitis. Multiple intra-abdominal abscesses were drained peroperatively. Two intra-abdominal drains were placed to maintain postoperative drainage of the abscess pockets. Postoperative management consisted of broad-spectrum antibiotics and therapeutic heparin for a thrombus in the left iliac vein. On postoperative day one the patient was extubated, and on postoperative day four she was transferred to the gastrointestinal surgery ward. She remained hemodynamically normal and her stoma production started. The neurological symptoms did not resolve completely during her stay. Eventually, the patient was returned to her primary care center 2 weeks after admission to our hospital. There she was enrolled in an intensive rehabilitation program for her persisting neurological symptoms.