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CASE REPORT
Year : 2003  |  Volume : 51  |  Issue : 1  |  Page : 71-72

Sudden bilateral foot drop: An unusual presentation of lumbar disc prolapse


Department of Neurosurgery, National Neurosurgical and Trauma Center, Khoula Hospital, Mina Al Fahal, Sultanate of Oman

Correspondence Address:
PO Box 374, Al Harthy Complex, Postal Code 118, Sultanate of Oman
kratikagomantel.net.om

 » Abstract 

Bilateral acute foot drop is reported in a 30-year-old healthy male. He presented with a 7-day history of sudden severe backache, radiating to both the lower limbs and 1-day history of sudden bilateral ankle weakness that progressed to bilateral foot drop within 6 hours. He also developed retention of urine. Investigations revealed a large central disc prolapse at L3-4 with significant canal stenosis at that level. Following surgery the patient had progressive improvement.

How to cite this article:
Mahapatra A K, Gupta P K, Pawar S J, Sharma R R. Sudden bilateral foot drop: An unusual presentation of lumbar disc prolapse . Neurol India 2003;51:71-2


How to cite this URL:
Mahapatra A K, Gupta P K, Pawar S J, Sharma R R. Sudden bilateral foot drop: An unusual presentation of lumbar disc prolapse . Neurol India [serial online] 2003 [cited 2020 Dec 1];51:71-2. Available from: https://www.neurologyindia.com/text.asp?2003/51/1/71/1037


Compression of the cauda equina is an uncommon presentation of lumbar disc prolapse[1],[2],[3] and is reported in 3-10% cases.[2],[4],[6] Rarely, lumbar disc herniation may produce hemi-cauda equina syndrome.[7] Acute unilateral foot drop is well described.[2],[7] We report a rare case of a bilateral sudden foot drop, due to an acute central disc prolapse at L3-L4 level and review the relevant literature.

  »   Case Report
 Top

A 30-years-old man lifted a heavy weight and developed an acute severe low backache, radiating to both the lower limbs. There were no neurological deficits but straight leg raising test was restricted. He was managed on conservative therapy with analgesics and complete bed rest. Pain was relieved significantly. A day prior to admission, he suddenly developed weakness of both the legs and feet that progressed to bilateral foot drop and urinary retention within 6 hours. He also had impaired sensation in both legs and feet. On admission, neurological examination revealed hypotonic lower limbs with 0/5 power in both ankle dorsiflexors. Muscle power at the knee was 3-4/5. There was graded sensory loss in both the lower limbs below L3. Knee and ankle reflexes were absent bilaterally. There was no wasting of the muscles. There was tenderness over L4-L5 spinous processes and straight leg raising test was restricted to 45 degrees bilaterally.
Investigations revealed a large disc prolapse with significant thecal compression at L3-L4 [Figure - 1] & [Figure - 2]. An emergency L3 and L4 laminectomy was performed and a large extruded central disc was excised microsurgically. Following surgery the patient showed progressive neurological recovery. Patient also recovered in urinary continence. Follow-up 3 months later, showed grade 4+5 power at knees and ankle joints. However, the ankle jerks were still absent and knee jerks were diminished. Patient had resumed his normal activities.

  »   Discussion Top


Lumbar disc herniation is a common disorder but a classical cauda equina syndrome due to lumbar disc herniation is uncommon. It is reported in 1-10% cases.[1],[2],[7] Jennett[4] reported clinical features of cauda equina compression in a series of 25 cases, as early as 1956. A typical cauda equina syndrome is characterized by bilateral sciatica, weakness of the lower limbs, saddle hypoesthesia and bladder and bowel dysfunction. The cauda equina syndrome is rarely sudden.[7] Generally, it is gradual and progressive. Chang et al[2] presented 4 cases of cauda equina syndrome among 144 consecutive cases of lumbar disc herniation. Occasionally, cauda equina syndrome may be restricted to one side and is termed as hemi-cauda equina syndrome.[7]
Bilateral foot drop is a rare condition.Unilateral foot drop is a usual presentation of peroneal nerve palsy, due to mechanical compression[8] at the head of the fibula. It could also be due to nutritional or other neuropathy.[9] Rarely, cases have been reported due to disorders like anorexia nervosa.[8] Bilateral foot drop can also result from parafalcine lesion[10],[11],[12] and is characterized by spastic foot drop with hyperactive ankle jerks and positive Babinski sign. Our patient had an acute bilateral foot drop, due to a L3-L4 disc prolapse. None of the patients of cauda equina syndrome that were reported by Chang et al[2] had bilateral sudden foot drop. Among three patients who had an acute presentation, one of them had unilateral foot drop.
Radiologically, location of the disc is by and large, central and rarely paramedian.[2],[4],[10] Common sites of disc herniation that produce cauda equina compression are L4-L5 and L5-SI levels.[2],[4],[6],[7]
Presentation of these patients could be acute, subacute or chronic.[2],[3],[4],[7] Our patient had acute symptoms and developed bilateral ankle weakness and foot drop. Acute foot drop is rare and acute bilateral foot drop due to lumbar disc prolapse has not been reported earlier in the literature.
Acute lumbar disc prolapse producing cauda equina syndrome is a neurosurgical emergency.[2],[4],[6],[7],[13] Only one of the three patients in the series reported by Chang et al was operated within 12 hours, the others were operated on the 5th and the 14th day.[2] Our patient benefited from an emergency surgery and had almost complete recovery eventually. Kostnik et al[5] reported no correlation between the timing of surgery and the recovery of the bladder functions.
Recovery following lumbar disc surgery is unpredictable.[2],[4],[6] Factors that influence the outcome are the degree of damage to the nerve roots of the cauda and the degree of neurological deficits including bladder and bowel involvement.[2],[4],[13],[14],[15] Kostnik et al[5] emphasized the importance of the sensory loss in the saddle area as an indicator of progress of bladder function. In our patient, there was bilateral saddle hypoaesthesia indicating partially preserved sensory function and therefore the bladder function recovered almost completely. Scott[15] pointed out that the recovery of the bladder function and sensation over saddle area is simultaneous. There is an overall consensus that the recovery of the bladder function is slow.[3],[4],[14] Bladder recovery took 3 years and 4 years respectively in the patients reported by Chang et al.[2] Our patient had urinary retention prior to admission and he regained normal urinary functions by the 6th day after surgery. We feel that early surgery helps quicker recovery of bladder functions, as it prevents further loss of remaining neural function. 

 » References Top

1.Choudhary A, Taylor A. Cauda equina syndrome in lumbar disc disease. Acta Orthop Scan 1980;51:493-9.  Back to cited text no. 1    
2.Chang HS, Nakagawa H, Mizuno J. Lumbar herniated disc presenting with cauda equina syndrome. Long term follow up of four cases. Surg Neurol 2000;53:100­5.  Back to cited text no. 2    
3.Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery 1993;32:743-7.  Back to cited text no. 3    
4.Jennett W. A study of 25 cases of compression of the cauda equina by prolapsed intervertebral disc. J Neurol Neurosurg Psychiatr 1956;19:109-16.  Back to cited text no. 4    
5.Kostnik J, Harington I, Alexander D, et al. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg 1986;68A:386-91.  Back to cited text no. 5    
6.Robinson R. Massive protrusion of lumbar disc disease. Br J Surg 1965;52:858-65.  Back to cited text no. 6    
7.Bartels RHMA, de Vries J. Hemi-cauda equina syndrome from herniated lumbar disc: a neurosurgical emergency? Can J Neurol Sci 1996;23:296-9.  Back to cited text no. 7    
8.Kershenbaum A, Jaffa T, Zeman A, et al. Bilateral foot drop in-patient with anorexia nervosa. Int J Eat Disord 1997;22:335-57.  Back to cited text no. 8    
9.Gariballa SE, Gunashekhar NP. Bilateral foot drop, weight loss and rectal bleeding as an acute presentation of crohns disease. Postgrad Med J 1994;70:762-3.  Back to cited text no. 9    
10.Guthrie BL, Ebersold MJ, Scheithauer BW. Neoplasms of the intracranial meninges. In: JR Youman, editor. Neurological surgery. 3rd edn. Philadelphia: WB Saunder; 1990. Vol 5. pp. 3250-315.  Back to cited text no. 10    
11.Eskandary H, Hamzei A, Yasamy MT. Foot drop following brain lesion. Surg Neurol 1995;43:89-90.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Talbert OR. General methods of a clinical examination. In: JR Youman, editor. Neurological surgery. 3rd edn. Philadelphia: WB Saunder; 1990. Vol 1. pp. 17.  Back to cited text no. 12    
13.O'Laoire S, Crockard AH, Thomas DGT. Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disc prolapse. Br Med J 1981;282:1852-4.  Back to cited text no. 13    
14.Hellstrour P, Kortelain W, Koutturi M. Late urodynamic findings after surgery for cauda equina syndrome caused by a prolapsed lumbar intervertebral disk. J Urol 1986;135:308-12.  Back to cited text no. 14    
15.Scott P. Bladder paralysis in cauda equina lesions from disc prolapse. J Bone Joint Surg 1965;47B:224-35.  Back to cited text no. 15    

 

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