Abstract
RATIONALE: Occult cerebrospinal fluid (CSF) leakage after lumbar spine surgery is common; however, cases in which CSF leakage leads to cauda equina tethering are rare and may result in severe neurological symptoms. This study elucidates the diagnostic challenges and management strategies for this rare complication through a representative case report. PATIENT CONCERNS: A 74-year-old man was diagnosed with lumbar spinal stenosis and lumbar disc herniation. He underwent lumbar decompression, fusion, and internal fixation. On the day following discharge, he developed bilateral hip and lower limb pain and numbness that did not respond to oral analgesics. DIAGNOSES: Tethered cauda equina syndrome caused by occult CSF leakage and a dural defect following lumbar spinal stenosis surgery. INTERVENTIONS: A second surgical exploration revealed an extradural pseudocyst and a dural defect. Clear CSF was observed within the cyst, and the cauda equina was entrapped and tethered. After careful release and dural repair, the patient's symptoms improved significantly. OUTCOMES: The patient experienced pain relief and regained independent mobility and daily function. LESSONS: Prolonged negative pressure drainage in the presence of CSF leakage may lead to nerve root tethering. Drainage duration should be carefully balanced to prevent infection while avoiding nerve entrapment. Timely surgical intervention can effectively relieve nerve compression and improve outcomes. This case highlights the need for heightened vigilance regarding delayed neurological deterioration following spinal surgery, emphasizing the critical importance of early recognition and intervention.