Cauda equina movement during the Valsalva maneuver in two patients with Lumbar spinal canal stenosis

Abstract

Lumbar spinal canal stenosis (LSS) is a common spinal disorder among older people. Some LSS patients say that their pain worsens when they lift heavy objects. The Valsalva maneuver is the optimal breathing pattern for producing maximal force. Herein, we present two cases of LSS where the movement of the cauda equina was observed during the Valsalva maneuver.Case Summary:Case 1: A 74-year-old female with a history of LSS presented to our Department of Urology with frequent urination. The patient was diagnosed as having uterine and bladder prolapse. Pelvic cine MRI scan was conducted for detailed evaluation. While the Valsalva maneuver was performed to diagnose pelvic organ prolapses, we observed movement of the cauda equina. Spine MRI and CT, performed one year before presentation, showed severe LSS due to degenerative spondylolisthesis.Case 2: A 73-year-old male underwent radical prostatectomy for prostate cancer. A follow-up cine MRI to confirm urethrorrhea showed the cauda equina moving during the Valsalva maneuver. Moderate LSS due to degenerative spondylolisthesis was retrospectively found on abdominal CT performed before prostatectomy.Conclusion: The findings of our report suggest that movement of the cauda equina during the Valsalva maneuver may be implicated in LSS.

Keywords: Cauda equina; Cine MRI; Lumbar spinal canal stenosis; Valsalva maneuver.

Fig. 1.

A 74-year-old female with a history of lumbar spinal canal stenosis (Case 1). Cine MRI shows a large movement of the cauda equina in an inchworm-manner during the Valsalva maneuver. The same image is shown in Supplemental Movie 1.

Fig. 2.

A. T2WI shows uterine and bladder prolapses (Case 1). B and C. Cine MRI during the Valsalva maneuver also shows uterine and bladder prolapses (Case 1).

Fig. 3.

A, T2WI (sagittal); B, T1WI (sagittal); C, T2WI (L3/4 axial); D, T2WI (L4/5 axial); E, CT (sagittal bone window setting); F, CT (sagittal soft tissue window setting); G, CT (L3/4 soft tissue window setting); and H, CT (L4/5 soft tissue window setting); (Case 1); spine MRI and CT performed one year before presentation showed severe lumbar spinal canal stenosis at L4/5 due to grade 2 lumbar spondylolisthesis in the Meyerding classification, and moderate stenosis at L3/4 due to grade 1 spondylolisthesis.

Fig. 4.

A 73-year-old male (Case 2). The cine MRI shows a small movement of the cauda equina during the Valsalva maneuver. The same image is shown in Supplemental Movie 2.

Fig. 5.

A, CT (sagittal bone window setting); B, CT (sagittal soft tissue window setting); and C, CT (L3/4 axial soft tissue window setting); (Case 2); Moderate lumbar spinal canal stenosis due to L3/4 grade 1 lumbar spondylolisthesis in the Meyerding classification was retrospectively found on abdominal CT performed before prostatectomy.