A Rare Occurrence of Cauda Equina Syndrome Following Chiropractic Manipulation: A Case Report

Case Diagnosis: 30-year-old Female with Cauda Equina Syndrome following Chiropractic Lumbar Spine High Velocity, Low Amplitude (HVLA) Manipulation

Case Description or Program Description: The patient was receiving chiropractic therapy for chronic low back pain over the last eight years. One hour following her most recent chiropractic therapy, acute onset of right greater than left lower extremity weakness with hypoesthesia and bladder incontinence developed. Magnetic resonance imaging of the lumbar spine revealed central and lateral recess stenosis at L1-2 and L2-3. Emergent decompressive laminectomies of L1-L2 and L2-L3 with discectomy were performed. She had residual neurogenic bladder, right greater than left weakness with dorsiflexion, plantarflexion, and extensor hallucis longus extension, and sensory deficits in L4-S1 distribution. A foley catheter was placed pre-operatively but needed re-insertion due to urinary retention. The patient also experienced bowel incontinence. The patient received physical and occupational therapies during their 10-day acute hospital stay and were then transferred to inpatient rehabilitation. Prior level of function was independent. Level of function on admission to IPR was maximum to moderate assist for mobility, and maximum assist for activities of daily living.

Setting: Tertiary Medical Center, Inpatient Rehabilitation Unit

Assessment/Results: The patient is still currently admitted to inpatient rehabilitation. To date, they are performing lower body dressing at touch assist level, moderate assist for transfers and sit-to-stand, ambulating with a rollator, and performing wheelchair mobility independently. Constipation developed secondary to stool impaction requiring manual evacuation. She is voiding spontaneously. Severe distal BLE weakness persists but hypoesthesia is improving.

Discussion (relevance): To our knowledge, this is the first reported case of cauda equina syndrome following high-velocity, low-amplitude manipulation of the lumbar spine. Additionally, we present unexpected sequelae of cauda equina syndrome.

Conclusions: Physiatrists must be selective in their recommendations for alternative pain management modalities. We must also recognize unique neurologic manifestations of cauda equina syndrome to optimize treatment to achieve functional recovery.