Lumbar disc herniation presenting with fecal incontinence without radiculopathy: A case report.

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. Copyright:

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.