Long-term recovery of cauda equina syndrome and sexual dysfunction following delayed decompression of a giant lumbar disc herniation: illustrative case

BACKGROUND: Cauda equina syndrome (CES) with sexual dysfunction is an uncommon but serious complication of lumbar disc herniation. Giant lumbar disc herniations, defined as occupying more than 50% of the spinal canal, can cause severe neural compression. Delayed decompression in CES is traditionally associated with poor neurological and autonomic recovery. OBSERVATIONS: A 36-year-old man presented with a 1-year history of low back pain and progressive radiculopathy, followed by 3 months of incomplete CES manifested by urinary dysfunction, constipation, saddle hypoesthesia, sexual dysfunction, and right foot drop. MRI revealed a giant L4-5 disc extrusion with a cranially migrated sequestered fragment measuring nearly 10 cm in total length and extending 1.7 cm behind the L4 vertebral body, resulting in marked thecal sac compression. The patient underwent delayed microsurgical excision of the disc fragment. Postoperatively, back and leg pain improved immediately. Urinary symptoms resolved by 24 months, and sexual function fully recovered by 40 months, whereas motor deficits and muscle wasting showed minimal improvement. LESSONS: Meaningful long-term recovery of bladder and sexual function is possible in incomplete CES despite delayed decompression, suggesting that neurological completeness at presentation may be a stronger prognostic factor than timing alone. https://thejns.org/doi/10.3171/CASE2647.