Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 38 Emergency (2016); 4 (1): 38-40 CASR REPORT Urinary Retention and Air in the Spinal Canal; a Case Report Mohammadmahdi Gheiratian, Hoda Karimian* Department of Emergency Medicine, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran. *Corresponding Author Hoda Karimian; Department of Emergency Medicine, Rasoul Akram Hospital, Niayesh St. Sattarkhan Ave. Tehran, Iran. Tel: 0098(021)66525327. Fax: 0098(021)66525327. E-mail: h_k_medicine@yahoo.com Received: April 2015; Accepted: June 2015 Abstract Cauda equina syndrome (CES) although uncommon, is a very serious condition, which should be diagnosed as soon as possible. Urinary dysfunction following a lumbosacral trauma is a key for the physician to consider CES as the most probable diagnosis. Up to 62% of CES patients report a recent episode of trauma. We herein report a young man with CES due to sacral fracture with an interesting imaging. Key words: Polyradiculopathy; lumbosacral region; spine; urinary retention. Cite this article as: Gheiratian MM, Karimian H. Urinary retention and air in the spinal canal; A case report. Emergency. 2016;4(1):38-40 Introduction: auda equina syndrome (CES) is a rare but highly impairing condition and is one of the few spinal surgical emergencies. This diagnosis refers to a complex of signs and symptoms resulting from compres- sion of nerve roots distal to the conus medullaris. Low back pain, motor weakness of lower limbs, sensory changes in saddle or perianal area, and loss of visceral function are some clinical manifestations of CES. How- ever, we should keep in mind that clinical diagnosis of CES is made only when bladder, bowel, or sexual dys- function and perianal or saddle numbness have occurred (1, 2). We herein report a young man with CES due to sa- cral fracture with an interesting imaging. Case report: A 19-year-old Afghan man was admitted to the emergency department (ED) because of urinary retention during the previous 24 hours. He was single and worked in a building as a laborer. He denied use of cigarettes, alcohol, and rec- reational drugs. In further investigation, he mentioned a trauma to his buttocks 3 to 4 days before, following a fall from an almost 3-meter height. He had been injured by a sharp material penetrating his right buttock. He had gone to a clinic and had his laceration sutured. On arrival to the C Figure 1: Axial computed tomography scan of sacrum shows bony fractured piece in the spinal canal. Figure 2: Axial computed tomography scan of sacrum shows air in the spinal canal, at level of sacral vertebrae. This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 39 Gheiratian and Karimian ED, he did not complain of low back pain or sacral pain, saddle paresthesia, urinary or fecal incontinence, weak- ness of lower extremities, or any other symptoms. He had normal vital signs. In physical examination he had tenderness over sacrum, saddle hypoesthesia, and normal rectal tone. Muscle forces of all limbs and deep tendon reflexes were normal and symmetric except for that of bilateral big toe exten- sion and flexion which were 3/5 and 4/5 respectively. Examination of the other parts did not reveal any posi- tive findings. A Foley catheter was fixed. Lumbosacral computed tomography (CT) scan was performed, which showed sacral laminar fracture of S1, S2, and S3 with dis- placement of fractured bone forwardly to the spinal ca- nal, and also air in the canal (figures 1, 2, and 3). Lum- bosacral magnetic resonance imaging (MRI) demon- strated compression of cauda equina by bony pieces (fig- ures 4 and 5). On the following day, he underwent sacral laminectomy of S1, S2, and S3, and fractured pieces were removed. In follow up, after almost 2 months he was completely symptom free with no complaint of urinary dysfunction or any other symptoms. Discussion: Urinary dysfunction following a lumbosacral trauma is a key for the physician to consider CES as the most proba- ble diagnosis. As a matter of fact, once suspected, the physician should seek for trauma history, as up to 62% of patients report a recent episode of trauma (3, 4). Like- wise, our patient presented with chief complaint of uri- nary retention and retrospectively his trauma history was figured out. According to the literature, etiologies for CES are various and the most common ones include spinal trauma, herniated lumbar disk, neoplasms includ- ing metastases, and spinal infection/abscess (5-11). As mentioned earlier, the diagnosis of CES is based on blad- der, bowel, or sexual dysfunction and perianal or saddle numbness. However, urinary dysfunction receives more attention because it shows itself sooner during the course of the disease compared to defecation dysfunc- tion which develops slower or sexual dysfunction which only becomes apparent later, when the patient goes back to normal life (12). J. G. Kennedy et al. established pre- dictors of outcome in CES in a retrospective review of 19 patients with CES. They reported that there was a statis- tically significant correlation between delayed decom- pressions of greater than 24 hours and poor outcome such as presence of complete saddle anesthesia (13). Alt- hough there is no clear agreement over the issue of tim- ing of surgery in CES patients with true urinary reten- tion, most authors are in favor of early decompression within the first 24 to 48 hours (11). Conclusion: Cauda equina syndrome, although uncommon, is a very serious condition, which should be diagnosed as soon as Figure 3: Axial computed tomography scan of lumbar spine shows air in the spinal canal at level of lumbar vertebrae. Figure 4: Sagittal T2 weighted magnetic resonance imaging shows compression of cauda equina by sacral fracture. Figure 5: Sagittal T1 weighted magnetic resonance imaging shows compression of cauda equina by sacral fracture. This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 40 Emergency (2016); 4 (1): 38-40 possible. Once suspected, the physician should give spe- cial consideration to a detailed history about possible etiologies, and do a thorough physical exam. The symp- toms are potentially reversible if surgical decompres- sion is made in a timely manner. Acknowledgments: The authors appreciate the insightful cooperation of Emergency Department staff of Rasoul Akram Hospital. Conflict of interest: None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. Jensen RL. Cauda equina syndrome as a postoperative complication of lumbar spine surgery. 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