{"paper_id":"ec482c33-9935-4adb-be2e-9a46c9ccfcbc","body_text":"Journal of Musculoskeletal Surgery and Research • Article in Press | 1\nCase Report\nCauda equina syndrome following vaginal hysterectomy \nin lithotomy position: A case report\n Zairul Nizam Zainol Fithri, MS Orth1, Izzatus S. Ariffin, Medical Student, MBBS1, Aishath I. Abdulla, Medical Student, \nMBBS1, Abdul W . Mohd Padzil, Dr Ortho and Trauma2\n1 Department of Surgery (Orthopaedics), IMU University, 2Department of Orthopaedics, Hospital Tuanku Jaafar Seremban, Seremban, Malaysia.\nINTRODUCTION\nCauda equina syndrome (CES) is an emergent condition, commonly attributed to an acute \nlumbar disc prolapse. [1] Other causes that can increase pressure over the cauda equina include \nretropulsion of fracture fragments, complications with spinal anesthesia, and epidural \nabscesses. Pre-existing spine conditions such as degenerative discopathy, spondylolisthesis, \nfacet arthropathy, and thickened ligamentum flavum can lead to spinal canal stenosis and \npredispose them to CES. In these patients, prolonged abnormal posture or trivial falls can \ncause sudden pressure on the nerve roots, leading to edema or hematoma formation. CES \nis a rare surgical emergency that warrants urgent diagnosis and treatment to prevent severe \ncomplications that can adversely affect a patient’s quality of life, with high medicolegal \nimplications.[1] Permanent dysfunctions can be expected in patients who are left untreated or if \nmanagement is delayed. We present an atypical presentation of CES, which developed following \na vaginal hysterectomy in the lithotomy position, only the second such case reported in the \nliterature. We intend to highlight the extremely rare but potentially devastating possibility of \ncord compression in patients undergoing such procedures, especially those with existing spinal \npathology.\nABSTRACT\nCauda equina syndrome (CES) is a rare but serious complication, often linked to spinal canal narrowing. We \npresent a unique case of CES following vaginal hysterectomy performed in the lithotomy position in a patient \nwith pre-existing spondylolisthesis. A 66-year-old woman with long-standing L4/L5 and L5/S1 spondylolisthesis \nunderwent vaginal hysterectomy. Postoperatively, she developed saddle anesthesia and burning urethral pain. \nInitially attributed to the gynecological procedure, her symptoms persisted. Three months later, a magnetic \nresonance imaging revealed spinal canal stenosis and CES. She underwent posterior lumbar interbody fusion, \nwhich improved her symptoms. This is only the second reported case of CES following vaginal hysterectomy \nin the lithotomy position. It underscores the importance of pre-operative spinal assessment and intraoperative \npositioning, especially in patients with known spinal pathology.\nKeywords: Case report, Cauda equina syndrome, Lithotomy, Spondylolisthesis, Vaginal hysterectomy\nHow to cite this article:  Zainol Fithri Z, Ariffin IS, Abdulla AI, Mohd Padzil AW . Cauda equina syndrome following vaginal hysterectomy in lithotomy \nposition: A case report. J Musculoskelet Surg Res. doi:  10.25259/JMSR_204_2025\nThis is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share \nAlike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the \nauthor is credited and the new creations are licensed under the identical terms. ©2025 Published by Scientific Scholar on \nbehalf of Journal of Musculoskeletal Surgery and Research\nwww.journalmsr.com\nJournal of Musculoskeletal Surgery \nand Research\nArticle in Press\n *Corresponding author: \nZairul Nizam Zainol Fithri, \nDepartment of Surgery \n(Orthopaedics), School of \nMedicine, IMU University \nClinical Campus, Jalan Rasah, \n70300 Seremban, Malaysia.\nzairulnizam@imu.edu.my\nReceived: 05 May 2025  \nAccepted: 03 July 2025  \nEpub ahead of print: 09 September 2025 \nPublished:\nDOI \n10.25259/JMSR_204_2025\nQuick Response Code:\n\n\nZainol Fithri, et al.: Cauda equina after vaginal hysterectomy\nJournal of Musculoskeletal Surgery and Research • Article in Press | 2\nCASE REPORT\nA 66-year-old female presented to her gynecologist with \nurinary stress incontinence, nocturia, and recurrent urinary \ntract infection for 2  years. It was discovered that she had a \nrectal mass, which was identified as Grade 2 uterine prolapse. \nShe also had a 30-year history of Meyerding I L4/L5 and \nL5/S1 spondylolisthesis with only intermittent back pain and \nno neurological deficits. The patient had no other medical \nor neurological conditions, including diabetes mellitus. She \nunderwent a nearly 4-h vaginal hysterectomy in lithotomy \nposition under general anesthesia with no intraoperative \ncomplications. Standard operative protocol related to \npositioning was adhered to. Histopathological results showed \nbenign findings, as explained to the patient. Following the \nsurgery, she developed severe perineal numbness, saddle \nanesthesia, painless perineal ulcers, and intermittent urethral \nburning pain. These post-operative complaints were regarded \nas being the result of her urogynecology procedure and thus \nmanaged conservatively.\nHer condition remained unattended and undiagnosed as \nan orthopedic problem until 3  months later, when fecal \nincontinence prompted further re-evaluation. Clinical \nexamination revealed reduced sensation in the perianal, \ngluteal, and posterior thigh areas, lax anal tone, and \nhyporeflexia of lower limbs but normal motor strength. \nMagnetic resonance imaging findings showed Meyerding I \nanterolisthesis at L4/L5 and L5/S1 with ligamentum flavum \nhypertrophy and facet joint hypertrophy over L3/L4, L4/L5, \nand L5/S1. There was significant spinal canal narrowing from \nL3 to S1 levels, leading to nerve root crowding [Figures 1 -3].\nWith a diagnosis of CES, the patient underwent urgent \nposterior lumbar decompression with interbody fusion \nsurgery. This involved directly decompressing the spinal \ncanal with L4 and L5 laminectomies and flavectomy of L3/\nL4, L4/L5, and L5/S1, and posterior lumbar interbody fusion \nusing iliac bone grafting at levels L4, L5, and S1 [Figure 4 ].\nThere was no new neurological deficit after the surgery. Over \ntime, her fecal incontinence resolved. Serial examinations \nnoted a tighter anal sphincter tone as compared to before \nsurgery. The burning sensation over her urethra and \nnumbness were improved gradually. Currently, she is on \nregular clean intermittent self-catheterization and bladder \ntraining to improve her urinary function. Despite the \nsignificant delay, the comprehensive surgical intervention \naddressed her neurological deficits and structural spinal \nabnormalities, and her neurological recovery is still in \nprogress at 6 months’ follow-up.\nDISCUSSION\nCES is a rare orthopedic emergency with an estimated \nincidence of approximately 1 in 33,000–1 in 100,000. [1] One \nof the most devastating effects of an improperly diagnosed \nCES is the possibility of persistent neurological deficit; hence, \nthe urgency in both identifying patients presenting with CES \nand initiating prompt treatment.\nFigure  1: A case of a 66-year-old woman presenting with cauda \nequina syndrome following vaginal hysterectomy. (a) Pre-operative \nanteroposterior and (b) lateral radiographs showing the degree of \nL4/L5 and L5/S1 spondylolisthesis (red arrows).\nba\nFigure  2: A case of a 66-year-old woman presenting with cauda \nequina syndrome following vaginal hysterectomy. (a-c) Sagittal T2-\nweighted magnetic resonance imaging demonstrating Meyerding \nGrade I anterolisthesis at L4/L5 and L5/S1 (white arrows).\nba\nc\n\nZainol Fithri, et al.: Cauda equina after vaginal hysterectomy\nJournal of Musculoskeletal Surgery and Research • Article in Press | 3\nFollowing this patient’s vaginal hysterectomy, her neurological \nsymptoms were initially dismissed as a transient consequence \nof the procedure, leading to a delay in diagnosis and \ntreatment. Classical red flag symptoms of perineal numbness \nand fecal incontinence prompted the patient’s re-evaluation. \nWe postulate that her prolonged surgery (more than 3 h) in \na lithotomy position may have caused enough stress on the \nlumbosacral region to tip the balance toward CES.\nIt has been established that patients with spondylolisthesis \nhave a reduced spinal canal volume in the affected area \ncompared to normal subjects, and that this volume further \ndecreases when the patient is upright and in extension. [2] In \nthe lithotomy position, although the patient may be supine, \nhip and knee flexion, coupled with a tilting of the pelvis, \nmay reverse the lumbar lordosis. This may be exacerbated \nif a patient’s hips have been hyperflexed. It is possible that \noverzealous hip flexion during the gynecological procedure \nmay have tilted the pelvis and forced the slipped segment \ninto extension, further compromising the canal volume \nand resulting in her post-operative presentation. This is \nour postulation, as definitive data relating to biomechanical \nchanges during the lithotomy position is lacking. In one of the \nclassic studies conducted in 1970, Nachemson and Elfström \nmeasured intradiscal pressures during various postures and \nexercises; however, this did not include a position resembling \nlithotomy.[3] Regardless, extrapolating their results, we can \ninfer that being in the lithotomy position, particularly over \nprolonged periods, may increase anterior disc compression, \ncausing it to bulge into an already restricted spinal canal \nspace.\nGleave and Macfarlane discussed the different clinical \npresentations of CES and classified them as either CES \nincomplete or those having CES retention (CESR), and how \nthey relate to surgical outcome. [4] In a later review, Lavy \net al. proposed three additional subclasses. [5] Based on these \ncategorizations, we suspect that our patient most likely fell \ninto the CESR category because of her fecal incontinence \nand completely insensate perineum. Despite the worse \nprognosis in patients with CESR, surgical decompression was \nattempted.\nWe could only find a limited number of similar cases \nreported in the literature. Garry et al. reported an acute case \nof CES following an abdominal hysterectomy under general \nanesthesia.[6] Similar to our case, their patient had an existing \nslippage of the lumbosacral spine, had been placed in \nlithotomy position, and had endured a prolonged operative \ntime under general anesthesia. The authors, however, did not \nventure possible mechanisms to explain the pathology.\nFigure  4: A case of a 66-year-old woman presenting with cauda \nequina syndrome following vaginal hysterectomy. (a) Post-operative \nanteroposterior and (b) lateral radiographs showing interbody \nfusions at levels L4, L5, and S1.\nba\nFigure 3: A case of a 66-year-old woman presenting with cauda equina syndrome following vaginal \nhysterectomy. (a-c) Axial T2-weighted magnetic resonance imaging demonstrating spinal stenosis \nwith nerve root overcrowding (white arrows).\na b c\n\nZainol Fithri, et al.: Cauda equina after vaginal hysterectomy\nJournal of Musculoskeletal Surgery and Research • Article in Press | 4\nChoudhari et al.  reported on an acute intervertebral disc \nprolapse in a patient with a pre-existing canal stenosis who \nsimilarly underwent vaginal hysterectomy and presented \nthereafter with bilateral sciatica with lower limb numbness \nand attained significant relief with decompression surgery. [7] \nSingh et al. described two cases of acute lumbar disc prolapse \nin their report. [8] Both patients underwent vaginal \nhysterectomy in lithotomy positions under spinal anesthesia. \nIn their patients, both recovered with conservative measures. \nLike us, the authors postulated that manipulation of the \npatient in lithotomy position with the hips abducted and \nflexed likely resulted in a disc prolapse. Their patients, \nhowever, presented with radiculopathy rather than CES like \nours did.\nIt is known that lithotomy positions may result in several \nneurological complications, and these are generally \ncompressive and/or traction injuries in the form of \nneuropraxia, in which recovery is expected. [7,8] Flanagan \net al . had previously explained this traction injury \nmechanism in their description of their own cases.[9] The use \nof regional anesthesia itself could have a role in producing \npost-operative neurological complications. Intracanal \nbroaching for anesthesia might precipitate CES for such \nreasons as an inappropriately placed catheter. [1] However, \nour patient underwent a vaginal hysterectomy under general \nanesthesia, making this case unique. Her spondylolisthesis \nremained unchanged at Meyerding grade 1 before and after \nher hysterectomy and had been stable without neurological \nsymptoms for decades. It is unlikely that the cauda equina \npresentation is due solely to the listhesis, as the risk for such \noccurrence is generally low. [10] The stress incontinence that \nthe patient had before surgery is most likely related to her \nuterovaginal prolapse rather than spinal cord compression, \nas no other manifestations were present.\nNone of the authors cited above was able to provide conclusive \nevidence as to the cause of their patients’ post-operative \nsymptoms. We are only able to postulate our conclusions \nbased on the timing of the symptom presentation, absence \nof other causes, and inference from available data, although \nindirectly related. Being such a rare occurrence, we would \nrequire either further cadaveric or computer modelling \nto procure a definite date. We propose, based on these \nobservations, that positioning during surgery might be \nimplicated in this patient’s symptoms. Due to the rarity of \nthis type of complication, it is difficult to ascertain whether \na pre-operative orthopedic consult would have altered the \noutcome. However, extra vigilance to positioning could have \nbeen exercised, and more importantly, earlier identification \nand management of the CES could have been made.\nDue to the retrospective nature of the diagnosis, our inability \nto identify a direct causality is a limitation. Given the history, \nradiological and operative findings, and post-operative \nimprovement, a posture-related exacerbation of the spinal \npathology is the most likely mechanism. We would need \nfurther biomechanical and modelling studies to verify this.\nCONCLUSION\nThis rare case highlights a potentially devastating \ncomplication of CES in a patient with pre-existing spinal \npathology undergoing procedures in the lithotomy position. \nThe postulated mechanism discussed suggests that this \ncomplication is not limited to gender. It underscores the \nimportance of pre-operative planning, proper positioning, \nand post-operative cognizance in such patients, particularly \nthose undergoing prolonged procedures. The hazards \ninvolved may result in long-standing, even permanent, \ndebilitating consequences, particularly urogenital \ncomplications. Given the morbidity and medicolegal \nimplications, we therefore recommend a detailed work-up \nand urgent orthopedic consultation in patients presenting \nwith similar post-operative complaints. Future research, \nincluding biomechanical modelling, may help shed more \nlight on the precise mechanism and risks associated with the \nlithotomy position in at-risk patients.\nAuthors’ contributions: ZNZF , ISA, AIA: Contributed to literature \nsearch, data acquisition, data analysis, manuscript preparation, and \nmanuscript editing and review. AWMP: Contributed to manuscript \nediting and review. All authors have critically reviewed and \napproved the final draft and are responsible for the manuscript’s \ncontent and similarity index.\nEthical approval: Institutional Review Board approval is not \nrequired. Approval and consent were obtained from hospital \nmanagement before manuscript submission (P1-Ver 3.1-22/04/2019 \nDated May 05, 2025).\nDeclaration of patient consent:  The authors certify that they \nhave obtained all appropriate patient consent forms. In the form, \nthe patient has given her consent for her images and other clinical \ninformation to be reported in the journal. The patient understands \nthat her name and initials will not be published, and due efforts \nwill be made to conceal her identity, but anonymity cannot be \nguaranteed.\nUse of artificial intelligence (AI)-assisted technology for \nmanuscript preparation: The authors confirm that there was no \nuse of AI-assisted technology for assisting in the writing or editing \nof the manuscript, and no images were manipulated using AI.\nConflicts of interest: There are no conflicting relationships or \nactivities.\nFinancial support and sponsorship: This study did not receive any \nspecific grant from funding agencies in the public, commercial, or \nnot-for-profit sectors.\nREFERENCES\n1. Gardner A, Gardner E, Morley T. Cauda equina syndrome: \nA review of the current clinical and medico-legal position. Eur \n\nZainol Fithri, et al.: Cauda equina after vaginal hysterectomy\nJournal of Musculoskeletal Surgery and Research • Article in Press | 5\nSpine J 2011;20:690-7.\n2. Miao J, Wang S, Park WM, Xia Q, Fang X, Wood K, et al . \nSegmental spinal canal volume in patients with degenerative \nspondylolisthesis. Spine J 2013;13:706-12.\n3. Nachemson A, Elfström G. Intravital dynamic pressure \nmeasurements in lumbar discs. A  study of common \nmovements, maneuvers and exercises. Scand J Rehabil Med \nSuppl 1970;1:1-40.\n4. Gleave JR, Macfarlane R. Cauda equina syndrome: What is \nthe relationship between timing of surgery and outcome? Br J \nNeurosurg 2002;16:325-8.\n5. Lavy C, Marks P , Dangas K, Todd N. Cauda equina syndrome-a \npractical guide to definition and classification. Int Orthop \n2022;46:165-9.\n6. Garry CB, Cho WJ, Job AV , Sharan AD. Acute postoperative \ncauda equina syndrome following an elective gynecological \nprocedure. Indian Spine J 2022;5:125-8.\n7. Choudhari K, Choudhari Y , Fannin T. Acute lumbar \nintervertebral disc prolapse: A  complication of the lithotomy \nposition. Br J Obstet Gynecol 2000;107:1519-21.\n8. Singh N, Meenakshi J, Negi N. Acute lumbar disc prolapse: \nA  rare complication of lithotomy position. J  Gynecol Surg \n2015;31:367-9.\n9. Flanagan WF , Webster GD, Brown MW , Massey EW . \nLumbosacral plexus stretch injury following the use of the \nmodified lithotomy position. J Urol 1985;134:567-8.\n10. Li N, Scofield J, Mangham P , Cooper J, Sherman W , Kaye AD. \nSpondylolisthesis. Orthop Rev (Pavia) 2022;14:36917.","source_license":"CC0","license_restricted":false}