Hello, all. Hope everyone is doing well. I had a pretty exciting
day last week that I'd like to share with everyone. I'm going to
set this up kind of like a case report, so try to read the case
without looking at the last part of the blog, and try to formulate
your own differential diagnosis and next appropriate steps in
management. Mind you, this is a real case that presented to the
clinic last week, so this does happen!
Case Report
A 24-year-old male who has been under your care for 3 weeks
for insidious onset of back pain, presents to your office 3 days
after his last appointment with a new chief complaint of difficulty
urinating. Hopefully some bells are starting to go off already. The
patient relates that after his treatment 3 days prior, which
included IFC, ice therapy and a Thompson drop counter-nutation
sacral adjustment, he has had difficulty urinating but his low back
has been feeling much better. Upon questioning, the patient states
he has been drinking about 120-170 ounces of water per day since
the onset of urinary difficulty in hopes of having a complete void
of his bladder, but has only experienced "dribbling" urinary flow,
and feels as if he has to go every 10-15 minutes. The patient had
not tried to forcefully urinate in fear of "hurting himself" and
has not experienced any loss of control with coughing, sneezing or
laughing. Patient denied any bowel issues, any burning with
urination, loss of muscular function in the lower extremities, or
any abnormalities in lower extremity sensation. It was suggested
that if the patient had to urinate at any time during the
appointment for him to try to forcefully push out the urine; he did
go to the bathroom, but was unable to forcefully urinate. Before a
physical exam could be performed the patient began to experience a
deep cramping low back pain that referred somewhat to his flanks
and down the lateral portion of both legs to about the knees. At
this point the patient was told to make his way directly to the
emergency room.
Thoughts?
So what are you thinking? By this time you should have at least
3 differential diagnoses rolling around in your noggin. The first,
and most severe thought should be Cauda Equina Syndrome (CES). My
other two differentials included nephro- or uretero-lithiasis
(kidney or ureter stone), and possibly a urinary tract infection.
The reason the patient was immediately asked to make an emergency
room trip was to rule out CES and if surgery or decompression was
necessary, he was at the hospital already.
Cauda Equina Syndrome is a serious neurological condition that
occurs when nerves of the spinal cord beyond the conus medullaris
(the cauda equina) are impacted and the functions they control are
disturbed. A disc herniation, a tumor, or any other space-occupying
lesion could cause the neural compression. With the patient's
history of aching low back pain, with progressive loss of the
ability to use his detrussor muscles (the muscles which push urine
flow), it was our concern that he may be on the verge of bladder
rupture, and/or ascension of urine back into the kidneys which
could cause a whole slew of other problems including hydronephrosis
and maybe even death.
The patient was very fortunate that an MRI study of his lumbar
spine revealed no compression of the cauda equina. I hope no one
thinks that this was a waste of time sending the patient out for
advanced imaging. As a physician you must always put the patient's
well being above all else. There would be no way I would be able to
sleep at night if I discounted a patient's signs and symptoms and
down-played a condition which ended up hurting the patient
indefinably. The patient was extremely relieved that he was
CES-free, but he isn't out of the woods yet. He still is having
urination issues, and therefore we referred him to an urologist for
consultation. You have to know when something is out of your scope
of practice, and not be too proud to refer someone to a physician
who could help them.
Well, I hope someone took something away from this patient
encounter of ours down here in the Florida clinic. Remember to
always put your patient first, and an expensive procedure to rule
out a life threatening condition will always be worth the money. If
anyone has any questions on Cauda Equina Syndrome or appropriate
management, shoot me an email and I'll do my best to find out any
answers you may have.
Have a great week,
Dex