Recommended Citation
Hussain H, Ghaly R . Challenges in the management of a patient with cauda equina syndrome and an incidental anterior mediastinal thymoma. Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Presentation Notes
Presented at: Midwest Anesthesia Residents Conference (MARC); April 26, 2025; Indianapolis, IN.
Abstract
Introduction: Cauda equina syndrome (CES) is a neurosurgical emergency that often necessitates urgent decompressive surgery. However, the presence of an anterior mediastinal mass poses significant perioperative risks, particularly when extensive spinal fusion is required in the prone position. This case highlights the unique challenges encountered in the surgical planning and execution for an 83-year-old female presenting for lumbar spine surgery with a newly discovered thymoma. Case Presentation: An 83-year-old female with a 10-year history of progressive neurogenic claudication, severe lower extremity pain, and severe mobility impairment presented for surgical intervention for CES. She exhibited profound lower extremity weakness (2-3/5 strength), an inability to stand from a seated position without upper extremity support, and severe kyphotic posture to relieve pain. MRI confirmed severe spinal stenosis at multiple lumbar levels, with a complete block at L3-L4 and L4-L5. Given the severity of the condition, an extensive decompressive laminectomy and fusion were deemed necessary. Preoperative evaluation incidentally revealed an 8 x 5.5 x 5.5 cm anterior mediastinal mass concerning for thymoma. The mass was deemed a contraindication for prone positioning due to potential airway compression and hemodynamic instability. Extensive multidisciplinary discussions were conducted to assess surgical feasibility and anesthetic risk mitigation strategies. The patient underwent L1-L5 decompressive laminectomy, L3-L5 instrumented fusion, and deformity correction. Intraoperative management included careful airway monitoring and limited muscle relaxation to prevent mediastinal compression effects. She tolerated the prone position without cardiorespiratory compromise. Postoperatively, the patient demonstrated marked neurological improvement. By her three-month follow-up, she was ambulating independently, had resumed daily activities, and was pain-free. Subsequent imaging confirmed a stable thymoma without significant progression. Conclusion: This case underscores the complexities of managing CES in the setting of an incidental anterior mediastinal mass. While mediastinal pathology typically precludes prone positioning, thorough risk stratification and intraoperative vigilance facilitated a successful lumbar decompression and fusion. This report highlights the importance of a multidisciplinary approach in optimizing surgical outcomes when competing pathologies exist. Prone positioning with mediastinal masses warrants special attention to anesthetic considerations including airway management, hemodynamic stability, and neuromuscular blockade adjustments. 1. Sarkiss, M et al. (2023). Mediastinum, 7, 16. 2. Hartigan, Philip M et al. (2022) Anesthesiology 136: 104-114. 3. P. Slinger (ed.), Principles and Practice of Anesthesia for Thoracic Surgery, 2011
Type
Oral/Podium Presentation
Affiliations
Advocate Illinois Masonic Medical Center