Louisiana State University Health Sciences Center Baton Rouge, LA, United States
Blake D. Savoie, MD, MS, BS1, Casey Chapman, MD2, Diana Hamer, PhD1 1Louisiana State University Health Sciences Center, Baton Rouge, LA; 2Baton Rouge General Medical Center, Baton Rouge, LA
Introduction: Inflammatory bowel disease is typically associated with intestinal pathology. However, extraintestinal manifestations are often misdiagnosed and may cause serious complications for our patients. We present a case of a patient that develops sacroiliitis and cauda equina syndrome due to poorly controlled Crohn’s disease.
Case Description/Methods: A 26-year-old female with severe Crohn's disease presented to the emergency department with complaints of progressive back pain. She began experiencing symptoms one-week prior starting with leg weakness which progressed to the point where she had trouble ambulating and was experiencing loss of continence. She had been treated with biologics in the past with periods of disease control, but experienced several relapses due to nonadherence to medical therapy.
At time of presentation, initial evaluation revealed weakness with reduced ability to move both lower extremities and paresthesias. An MRI of the patient’s lumbar spine and pelvis showed prominent changes of sacroiliitis related to the left sacroiliac joint with mild sclerosis and prominent sacral edema. An X-ray guided bone biopsy revealed findings consistent with Crohn’s associated sacroiliitis.
The patient required a sacroiliac joint fusion due to ongoing pain. Following this, she was then started on appropriate biologic therapy. At follow up after three months, the patient had regained function in her lower extremities and recovered bladder continence.
Discussion: Cauda equina syndrome typically results from some pathology causing compression within the canal of the lumbosacral spine. Depending on the rate of compression, patients can experience back pain, sciatica, saddle anesthesia, lower extremity sensorimotor loss, and finally bladder and bowel dysfunction. The insidious onset from this patient’s poorly controlled Crohn's disease likely led to ongoing inflammation and resulted in her presentation. There are no screening recommendations for these diseases outside of the development of symptoms.
Treatment options for poorly controlled sacroiliitis and Crohn's disease typically necessitates the use of biologic therapy. In the case of cauda equina syndrome, prompt intervention is necessary to reverse any long-term neurological complications.
Our patient is fortunate that her condition was able to be intervened upon. She did regain neurological function but did have to undergo an invasive procedure for ongoing joint pains. Proper therapy may have prevented her presentation and the need for surgery.
Figure: MRI of the sacroiliac joint showing diffuse inflammation and edema
