Abstract

Background: Lumbar disc herniation (LDH) usually presents with lower extremity symptoms and signs, but rarely with bladder and bowel complaints. Here, we present a 61-year-old female who suffered solely from fecal incontinence (FI) attributed to a large LDH.

Case Description: The patient presented with FI, but had a normal neurological examination. When the lumbar magnetic resonance imaging of showed a large central L5S1 LDH, the patient underwent an urgent diskectomy. Six months later, her symptoms had improved.

Conclusion: Patients with large central LDHs may present with FI alone warranting urgent/emergent disc removal.

Keywords: Cauda equina syndrome, Fecal incontinence, Lumbar disc herniation

INTRODUCTION

Cauda equina syndromes (CESs) occur in from 1 to 3/100,000 patients. They are typically caused by herniated intervertebral lumbar discs at the L5-S1 level.[ 1 , 4 ]

CES, due to the lumbar discs, can be either complete or incomplete.[ 3 ] Notably, patients rarely soley present with fecal incontinence (FI) that may be relieved with timely surgical decompression.[ 3 , 4 ]

Here, we present a 61-year-old female with FI alone attributed to a large L5S1 lumbar disc herniation (LDH), seen on magnetic resonance (MR) (i.e. without further symptoms/signs). Urgent decompression/diskectomy resulted in significant improvement of her deficit.

CASE REPORT

A 61-year-old female patient presented with FI of subacute onset (i.e. occurring up to 6 times a week) for the past 5 weeks (Cleveland Clinic Fecal Incontinence Score [CCFIS] 18; severe incontinence). She had no accompanying; back pain, saddle anesthesia, radiculopathy, myelopathy, or urinary incontinence.

The high-resolution manometry (HRAM-pressure reading) of the anal canal and colonoscopy was normal. The MR imaging of the lumbar spine showed a large left-sided LDH at the L5-S1 level [ Figures 1 and 2 ] resulting in significant cauda equina compression. Following and urgent microdiscectomy, the patient demonstrated significant improvement in her FI (i.e. FI [CCFIS 13; moderate incontinence]).

Figure 1:

A 61-year-old female patient was admitted with transient fecal incontinence and an asymptomatic lumbar disc herniation: (a and b) magnetic resonance imaging sagittal T2 of the lower abdomen demonstrates a hernia between L5-S1 (sacrum) (arrow).

Figure 2:

A 61-year-old female patient was admitted with transient fecal incontinence and an asymptomatic lumbar disc herniation: (a-d) magnetic resonance imaging axial T2 thin slices 2.5 mm is sequence which was conducted with the abdomen coil after the observation of the existence of a hernia. A distracted intervertebral disk piece left, which presses the L5-S1 roots without creating vertebral stenosis (arrows).

DISCUSSION

Approximately 0.12% of the LDHs are likely to present with CES.[ 5 , 6 ]

CES, characterized by bladder and/or bowel dysfunction, saddle anesthesia, sexual dysfunction, and L5-S1 radiculopathy, is present in up to 2–6% of patients undergoing lumbar disc operations.[ 1 , 2 ] Here, FI (i.e. typically estimated according to the CCFIS) was the only manifestation of a CES attributed to the L5S1 disc herniation readily documented on an MR [ Table 1 ].[ 4 , 7 ] In these patients, urgent/emergent diskectomy, as in this case/largely provides symptomatic relief.

Table 1:

CCFIS score.[ 2]

CONCLUSION

Patients with large L5S1 disc herniation may present with FI alone warranting urgent/emergent surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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