Acute cauda equina syndrome due to lumbar spinal stenosis caused by prolonged supine position during cardiac catheterization: a case report

Background: Cauda equina syndrome (CES) is a severe neurologic condition marked by progressive loss of function of the neurologic elements in the spinal canal below the termination of the spinal cord. This article reports an instructive case of CES with acute aggravation of neuropathy after catheter ablation for atrial fibrillation. Patient concerns: A 63-year-old Japanese man underwent catheter ablation for atrial fibrillation. Because he complained of severe low back pain and numbness in the posterior of both lower limbs while in the supine position, he was given analgesia with pentazocine and sedated with propofol, and the procedure continued. He was then forced to maintain lumbar extension while in the supine position for 13 hours. After the treatment, he noticed urination disor-der, numbness, and paralysis of both lower limbs. Diagnosis: Neurological findings included sensory impairment and motor deficit of L5 and below, including bowel/bladder dysfunction. Lumbar magnetic resonance imaging showed severe lumbar spinal stenosis at L4-L5. He was diagnosed with CES due to lumbar spinal stenosis. Interventions: The patient received emergency surgery for L4-L5 decompression. Decompression of the spinal canal was achieved 33 hours after the start of catheterization. Outcomes: The patient’s leg symptoms improved immediately after surgery, and he was able to walk with a walker. On postoperative day 6, the urinary catheter was removed. However, he experienced urinary retention and needed intermittent self-directed urination. Five months after surgery, he was able to urinate on his own, and completed the intermittent self-directed urination. Nine months after surgery, his muscle strength had recovered almost completely, and he was able to walk with a cane. However, bladder dysfunction such as frequent urination and residual urination remained 4 years after surgery. Lessons: If the supine position elicits low back pain and leg numbness, the presence of lumbar spinal stenosis should be considered. Forcing patients with such symptoms into a sustained posture can lead to CES.