This case illustrates the failure to recognize the presence of acute CES, which was likely due to an atypical presentation, low index of suspicion, and improper follow-up. This delay in appropriate therapy led to the catastrophic sequelae.
Unfortunately, only one-fifth of the patients present with the classical triad of bilateral sciatica with lower limb weakness, saddle anesthesia, and sphincter disturbance . In this patient, the atypical presentation of the loss of sensation in the perineum in the absence of sciatica and lower limb weakness probably accounted for the initial delay in presentation. During this admission, the vulval abscess prompted the detection of the saddle sensory loss that had not been picked up even by the patient. Thereafter, piecing together of the evidence of the clinical evaluation, that is, vulval abscess, saddle sensory loss, overflow incontinence, hydronephrosis, renal compromise, and MRI evidence, gave the complete picture (Fig. 2). The timeline of the development of complications is shown in Fig. 3.
Unfortunately, if the bladder dysfunction was properly evaluated during previous admissions, an overflow incontinence due to a neurogenic bladder would have been elicited by clinical evaluation alone. This would have, in turn, prompted a neurological examination that would have revealed a CES. A painless urine retention in CES leads to permanent bladder damage from irreversible stretching of the bladder wall resulting in a palpable bladder. Therefore, it is essential in a case of neurogenic bladder dysfunction to screen for CES, even if they do not present with classic symptoms . Although this is basic undergraduate knowledge, it is common practice to look for urogynecological causes for incontinence rather than rare neurological causes. This compartmentalization of clinical features and the lack of a holistic approach to patient management is a result of involvement of multiple specialists in patient care. If catastrophes of this nature are to be prevented, actual discussion among clinicians and not mere referrals are needed, especially in the current concept of multidisciplinary care.
Diagnostic imaging with computerized tomography (CT) scan or magnetic resonance imaging (MRI) is mandatory in these cases. Surgical decompression, usually via laminectomy, is recommended if there is a disc herniation. It is generally accepted that CES is a surgical emergency as early decompression prevents irreversible neurological disability [2, 4, 5]. However, the lack of accurate imaging and prompt surgical decompression may be difficult to achieve in low-resource settings.
In summary, the triad of delayed presentation by the patient; physician-related factors such as not suspecting CES or referral to inappropriate speciality; and problems of low-resource settings such as delay or unavailability of magnetic resonance imaging (MRI) and inability to perform surgery due to a lack of beds or theater time in a tertiary care center will contribute to make an already bad situation worse . It is probable that all of these factors contributed to this patient’s outcome.