Cauda Equina Syndrome in a Pediatric Patient due to Lumbar Disc ...

J Med Sci 2011;31(6):275-277
http://jms.ndmctsgh.edu.tw/3106275.pdf
Copyright © 2011 JMS
Received: April 28, 2011; Revised: June 13, 2011;
Accepted: June 20, 2011
* Corresponding author: Shu-Shong Hsu, Division of
Neurosurgery, Kaohsiung Veterans General Hospital,
No. 386, Ta-chung 1st Road, Kaohsiung 813, Taiwan,
Republic of China. Tel: +886-7-3468113; Fax: +886-7-
3455064; E-mail : sshsu59@yahoo.com
Chia-Yuan Chang, et al.
Cauda Equina Syndrome in a Pediatric Patient due to Lumbar Disc Herniation
Chia-Yuan Chang 1 , Ping-Hong Lai 2 , and Shu-Shong Hsu 1*
1 Division of Neurosurgery, Department of Surgery;
2 Division of Neuroradiology, Kaohsiung Veterans General Hospital, Kaohsiung,
Taiwan, Republic of China
Lumbar disc herniation is rare in pediatric population and the management strategy remains unclear. Here, we present a
12-year-old boy with back pain radiating to bilateral lower limbs, weakness of bilateral lower limbs and urine retention.
MRI of L-spine disclosed lumbar disc herniation over L4/5 level and microdiscectomy was performed. Postoperatively,
the patient’s neurologic defi cit resolved gradually and he returned to school three weeks after operation.
We reviewed the related literature and discussed the possible mechanisms and treatment of lumbar disc herniation in pediatric
population.
Key words: lumbar disc herniation, pediatric patient, microdiscectomy, cauda equina syndrome.
INTRODUCTION
Lumbar disc herniation is mainly a disease of adults
and the reported lifetime occurrence rate of lumbar
disc herniation was as high as 40%. 1 The incidence of
lumbar disc herniation in pediatric population is much
lower than that in adults. The most common symptom of
lumbar disc herniation is back pain, leg pain and motor
weakness. 2,3 Cauda equina syndrome due to lumbar disc
herniation is rare both in adults and in pediatric population.
In this paper, a pediatric patient presented with cauda
equina syndrome due to lumbar disc herniation was reported.
Previous studies are reviewed and the possible
mechanism and management strategies are discussed.
CASE REPORT
A 12-year-old boy presented with back pain radiating
to bilateral lower limbs and weakness of bilateral lower
limbs especially on the left side 5 days before admission.
There was no trauma history. Physical examination
revealed decreased deep tendon refl ex of bilateral ankle
Fig. 1 T2-weighted sagittal MRI
showing a herniated disc at
L4-L5 (two arrows)
jerk reflex, grade
4 muscle power of
right knee fl exion,
foot dorsiflexion
and plantar flexion,
and grade 3
muscle power of
left knee flexion,
foot dorsiflexion
and plantar flexion.
Numbness of
perineal region
and bilateral lateral
side of lower
legs was noted.
No Barbinski refl
ex was observed.
Straight leg raising
test (SLRT)
was positive with
the right leg lifted
45 o off the bed and
the left leg lifted
30 o off the bed. Urine retention happened 3 days after
admission. Cystometry (CMG) revealed poor compliance
of urinary bladder. MRI of lumbar spine disclosed
generalized bulging disc between L4 and L5 level with
moderate to severe thecal sac compression. (Fig. 1 and
Fig. 2) Conservative treatment including analgesics and
physiotherapy did not improve his symptoms. Left L4
laminotomy and microdiscectomy were performed 5
days after admission.
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Cauda equina syndrome in a pediatric patient due to lumbar disc herniation
Fig. 2 Axial T1-weighted (left) and T2-weighted (right)
MRI of the L4-L5 level showing generalized bulging
disc (arrow) with severe thecal sac compression.
Postoperatively, the patient’s pain resolved and weakness
of bilateral lower limbs improvement gradually.
Urinary catheter was removed two weeks after operation.
He returned to school 3 weeks after operation and recovered
completely 6 months after operation. He remained
symptom free at one-year follow-up (Low Back Outcome
Score > 65).
DISCUSSION
Lumbar disc herniation is rare in pediatric population
and may be missed due to the absence of classical symptoms.
It was reported the pediatric patients constitute
only 0.5-6.8% of all patients hospitalized for lumbar disc
herniation. 4,5 The incidence of surgery for disc herniation
in patients younger than 20 years ranges from 0.92% to
2.1% of all disc surgeries. 6 The symptoms of pediatric
lumbar disc herniation are generally similar to those observed
in adults. They included back pain, radicular pain,
motor weakness, sensory impairment and cauda equina
syndrome. Up to 90-95% of pediatric patients have a
positive SLRT which can be explained by their greater
nerve root tension compared with that in adults. 2,7
While chronic degenerative changes constitute the
main cause for lumbar disc herniation among adults, the
etiology of lumbar disc herniation in pediatric patients
is unclear. Genetic factors leading to early degenerative
changes have been considered. 8 Studies have shown that
13%-57% of adolescents with lumbar disc herniation
have a first-degree relative having the same disorder.
Various reports have also revealed strong predisposition
of lumbar disc herniation by trauma while others have
found little association. 9,10,11 Microtrauma which cannot
be seen radiologically, may be a signifi cant contributing
factor in these cases.
It is diffi cult to decide on the management strategy for
276
lumbar disc herniation in pediatric population because
the growing spine is more vulnerable to surgical trauma
and iatrogenic deformities may develop after laminectomy.
The initial management of lumbar disc herniation
in pediatric patients is the same as that in adults and
involves mainly conservative treatment which includes
bed rest, analgesic, physical therapy and limitation of
physical activities. Short-term to long-term success
rate of conservative treatment for pediatric lumbar disc
herniation without neurologic defi cits varies from 25 to
50%. 2,9,12 Several studies have compared the outcome
between conservative treatment and discectomy. Kurth
et al. found no signifi cant difference in outcome among
33 pediatric patients (18 conservatively and 15 surgically
treated cases) with a follow-up of 5.4 years. 13 Kevin et
al. reported that among 44 new patients seeking consultation
for evaluation of lumbar disc herniation over a
one-year period, only 13 underwent surgical treatment. 2
Kurihara et al. reviewed 70 pediatric patients with disc
herniation, only 40% of the patients responded to conservative
treatment and the results after discectomy were in
general excellent. 9 DeLuca et al. found that over a 6-year
follow-up, the rate of good results was only 25% in the
nonoperative group managed with conservative treatment
versus 91% in the operative group with discectomy performed.
12 It has been widely agreed by most authors that
pediatric patients may not respond as well to conservative
treatment as adults. It may be because the herniated
nucleus pulposus of children, as compared with adults,
is less degenerated, more hydrated, soft and viscous. In
addition, it does not dry up and resorb like a degenerated
adult disc. 9,14
Commonly agreed indications for surgical intervention
on pediatric lumbar disc herniation include: (1)
severe pain refractory to 4-6 weeks of conservative treatment,
(2) disabling pain affecting one’s daily activities,
(3) cauda equina syndrome, (4) progressive neurological
defi cits, and (5) associating spinal deformities. 7 As in the
case of adults, surgical treatment for pediatric lumbar
disc herniation comprises percutaneous endoscopic discectomy
and microdiscectomy. Percutaneous endoscopic
discectomy was associated with short-term success rate
of 91.3 to 100% but no long-term follow-up had been
reported. The short-term success rate of microdiscectomy
ranged from 98 to 100% while the medium-term (5-10
years) and long-term (> 10 years) success rate dropped to
92 and 85%, respectively. 9,12,14 How much disc material
should be removed is a crucial question. A discectomy
with insuffi cient nucleus removal is likely to fail while
excessive nucleus removal can also lead to stenosing

change at operated disc level and degenerative change
at adjacent disc level. For pediatric patients, it is especially
important to maintain the integrity of the inner
part of the annulus where proteoglycan synthesis is the
most active. 15 Serdar et al. reported 17 pediatric patients
undergoing microdiscectomy with none of them developing
iatrogenic spinal deformities during a mean 60month
follow-up. 4 It is reported that cases with long-term
follow-up had higher re-operation rate than those with
medium-term follow-up. Papagelopoulos et al. calculated
the re-operation rate of 72 surgically treated cases using
Survivorship Analysis and suggested that the probability
that a patient would not need a re-operation was 80% at
10 years and 74% at 20 years after the initial operation. 14
Spinal fusion should not be performed routinely for pediatric
patients unless the symptoms contribute to instability.
Early post-operation complications include wound
hematoma, wound infection and discitis which are rarely
reported in pediatric patients.
In conclusion, pediatric lumbar disc herniation is rare
and conservative treatment should be the initial management.
For patients not responding to conservative
treatment or having neurologic deficit such as motor
weakness or cauda equina syndrome, discectomy should
be considered. With the operation performed by an experienced
surgeon, the operating time of microdiscectomy
can be minimized with less blood loss and short hospital
stay. Microdiscectomy is the appropriate treatment for
pediatric lumbar disc herniation. Long-term follow-up is
required because recurrence may occur years after treatment.
DISCLOSURE
The authors declare that they have no confl ict of interest.
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