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Zhao J, Chen G. Fever associated with machine activation after sacral neuromodulation: Case report. Int J Surg Case Rep 2024; 123:110219. [PMID: 39236623 PMCID: PMC11408015 DOI: 10.1016/j.ijscr.2024.110219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 08/20/2024] [Accepted: 08/25/2024] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Sacral neuromodulation (SNM) is commonly used in the treatment of refractory overactive bladder (OAB), non-obstructive urinary retention (NOR) and fecal incontinence. Here, we report an atypical symptomatic case to enrich the limited international case series. CASE PRESENTATION We report a case of a male patient with cauda equina nerve injury left over from a traumatic injury and dysfunction of urinary and fecal functions who, after undergoing phase I sacral nerve stimulator placement, developed fever when the machine was switched on, and the symptoms resolved when it was switched off. CLINICAL DISCUSSION Sacral neuromodulation (SNM) is commonly used in the treatment of refractory overactive bladder (OAB), non-obstructive urinary retention (NOR) and fecal incontinence. The patient did not develop a non-infectious fever after the injury, only after the SNM device was installed and activated, and the temperature returned to normal after shutdown. We hypothesize that on top of the patient's pre-existing nerve damage and disorders, the activation of the SNM somehow stimulated the relevant sites, causing the patient to develop a neurogenic fever. CONCLUSION We concluded that in this case, it is reasonable to consider that the patient's fever was closely related to the placement of the sacral nerve stimulator.
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Affiliation(s)
- Jialei Zhao
- Department of Urology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Gang Chen
- Department of Urology, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Wang Q, Hou G, Wen M, Ren Z, Duan W, Lei X, Yao Z, Zhao S, Ye B, Tu Z, Huang P, Xie F, Gao B, Hu X, Luo Z. How to assess the long-term recovery outcomes of patients with cauda equina syndrome before surgery: a retrospective cohort study. Int J Surg 2024; 110:4197-4207. [PMID: 38502853 PMCID: PMC11254269 DOI: 10.1097/js9.0000000000001336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/03/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Factors influencing recovery after decompression surgery for cauda equina syndrome (CES) are not completely identified. The authors aimed to investigate the most valuable predictors (MVPs) of poor postoperative recovery (PPR) in patients with CES and construct a nomogram for discerning those who will experience PPR. METHODS Three hundred fifty-six patients with CES secondary to lumbar degenerative diseases treated at Xijing Hospital were randomly divided into training ( N =238) and validation ( N =118) cohorts at a 2:1 ratio. Moreover, 92 patients from the 970 th Hospital composed the testing cohort. Least Absolute Shrinkage and Selection Operator regression (LASSO) was used for selecting MVPs. The nomogram was developed by integrating coefficients of MVPs in the logistic regression, and its discrimination, calibration, and clinical utility were validated in all three cohorts. RESULTS After 3 to 5 years of follow-up, the residual rates of bladder dysfunction, bowel dysfunction, sexual dysfunction, and saddle anesthesia were 41.9, 44.1, 63.7, and 29.0%, respectively. MVPs included stress urinary incontinence, overactive bladder, low stream, difficult defecation, fecal incontinence, and saddle anesthesia in order. The discriminatory ability of the nomogram was up to 0.896, 0.919, and 0.848 in the training, validation, and testing cohorts, respectively. Besides, the nomogram showed good calibration and clinical utility in all cohorts. Furthermore, the optimal cutoff value of the nomogram score for distinguishing those who will experience PPR was 148.02, above which postoperative outcomes tend to be poor. CONCLUSION The first pretreatment nomogram for discerning CES patients who will experience PPR was developed and validated, which will aid clinicians in clinical decision-making.
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Affiliation(s)
- Qiushi Wang
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
- Department of Orthopaedic, No. 970th Hospital of Joint Logistic Support Force of PLA, Yantai
| | - Guangdong Hou
- Department of Urology, Xijing Hospital, Air Force Medical University, Xi’an
| | - Mengyuan Wen
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
- School of Nursing, Shaanxi University of Traditional Chinese Medicine, Xianyang, Shaanxi, People’s Republic of China
| | - Zhongwu Ren
- Department of Orthopaedic, No. 970th Hospital of Joint Logistic Support Force of PLA, Yantai
| | - Wei Duan
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Xin Lei
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Zhou Yao
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Shixian Zhao
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Bin Ye
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Zhipeng Tu
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Peipei Huang
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Fang Xie
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Bo Gao
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Xueyu Hu
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
| | - Zhuojing Luo
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University
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Winsten MT, Fine J, Fahimuddin F, Baxter D, Auguste T. Cauda equina syndrome with surgical intervention in pregnancy during the periviable period. Spinal Cord Ser Cases 2024; 10:35. [PMID: 38734688 PMCID: PMC11088644 DOI: 10.1038/s41394-024-00646-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 04/02/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION Cauda equina syndrome (CES) following lumbar disc herniation is exceedingly rare in pregnancy and there is limited literature outlining management of CES in pregnancy. There is further limited data addressing the management of periviable pregnancies complicated by CES. CASE PRESENTATION A 38-year-old female at 22 weeks gestation presented with worsening lower back pain radiating to the right posterior lower extremity. She was initially managed with conservative therapy, but re-presented with worsening neurologic symptoms, including fasciculations and perineal numbness. Magnetic resonance imaging showed a large herniated disc at L4-5, and given concern for CES, she underwent emergent decompression surgery, which was complicated by a superficial wound dehiscence. She ultimately carried her pregnancy to term and had a cesarean delivery. The patient's residual neurologic symptoms continued to improve with physical therapy throughout the postpartum period. DISCUSSION Cauda equina syndrome is a rare spinal condition with potentially devastating outcomes if not managed promptly. Diagnosis and management of CES in pregnancy is the same as in non-pregnant patients, however, standardization of patient positioning for surgery, surgical approach, anesthetic use, and fetal considerations is lacking. A multidisciplinary approach is critical, especially at periviable gestational ages of pregnancy. Our case and review of the literature demonstrates that patients in the second trimester can be managed surgically with prone positioning, intermittent fetal monitoring, and continued management of the pregnancy remains unchanged. Given the rarity of these cases, there is a need for a consensus on management and continued care in pregnant patients with CES.
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Affiliation(s)
- Mary Taylor Winsten
- MedStar Washington Hospital Center Department of Obstetrics and Gynecology, Washington, D.C., USA.
| | - Jessica Fine
- MedStar Washington Hospital Center Department of Obstetrics and Gynecology, Washington, D.C., USA
| | - Fatimah Fahimuddin
- MedStar Washington Hospital Center Division of Maternal Fetal Medicine, Washington, D.C., USA
| | - Diana Baxter
- MedStar Washington Hospital Center Division of Maternal Fetal Medicine, Washington, D.C., USA
| | - Tamika Auguste
- MedStar Washington Hospital Center Department of Obstetrics and Gynecology, Washington, D.C., USA
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Kong Q, Li F, Sun K, Sun X, Ma J. Valproic acid ameliorates cauda equina injury by suppressing HDAC2-mediated ferroptosis. CNS Neurosci Ther 2024; 30:e14524. [PMID: 38105511 PMCID: PMC11017456 DOI: 10.1111/cns.14524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 12/19/2023] Open
Abstract
INTRODUCTION Persistent neuroinflammatory response after cauda equina injury (CEI) lowers nociceptor firing thresholds, accompanied by pathological pain and decreasing extremity dysfunction. Histone deacetylation has been considered a key regulator of immunity, inflammation, and neurological dysfunction. Our previous study suggested that valproic acid (VPA), a histone deacetylase inhibitor, exhibited neuroprotective effects in rat models of CEI, although the underlying mechanism remains elusive. METHODS The cauda equina compression surgery was performed to establish the CEI model. The Basso, Beattie, Bresnahan score, and the von Frey filament test were carried out to measure the animal behavior. Immunofluorescence staining of myelin basic protein and GPX4 was carried out. In addition, transmission electron microscope analysis was used to assess the effect of VPA on the morphological changes of mitochondria. RNA-sequencing was conducted to clarify the underlying mechanism of VPA on CEI protection. RESULTS In this current study, we revealed that the expression level of HDAC1 and HDAC2 was elevated after cauda equina compression model but was reversed by VPA treatment. Meanwhile, HDAC2 knockdown resulted in the improvement of motor functions and pathologic pain, similar to treatment with VPA. Histology analysis also showed that knockdown of histone deacetylase (HDAC)-2, but not HDAC1, remarkably alleviated cauda equina injury and demyelinating lesions. The potential mechanism may be related to lowering oxidative stress and inflammatory response in the injured region. Notably, the transcriptome sequencing indicated that the therapeutic effect of VPA may depend on HDAC2-mediated ferroptosis. Ferroptosis-related genes were analyzed in vivo and DRG cells further validated the reliability of RNA-sequencing results, suggesting HDAC2-H4K12ac axis participated in epigenetic modulation of ferroptosis-related genes. CONCLUSION HDAC2 is critically involved in the ferroptosis and neuroinflammation in cauda equina injury, and VPA ameliorated cauda equina injury by suppressing HDAC2-mediated ferroptosis.
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Affiliation(s)
- Qingjie Kong
- Department of OrthopedicsShanghai General Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
- National Key Laboratory of Medical Immunology & Institute of ImmunologySecond Military Medical UniversityShanghaiChina
| | - Fudong Li
- Department of Orthopedic SurgerySpine Center, Shanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Kaiqiang Sun
- Department of Orthopedic SurgerySpine Center, Shanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Xiaofei Sun
- Department of Orthopedic SurgerySpine Center, Shanghai Changzheng Hospital, Second Military Medical UniversityShanghaiChina
| | - Jun Ma
- Department of OrthopedicsShanghai General Hospital, Shanghai Jiao Tong University School of MedicineShanghaiChina
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Trager RJ, Baumann AN, Perez JA, Dusek JA, Perfecto RPT, Goertz CM. Association between chiropractic spinal manipulation and cauda equina syndrome in adults with low back pain: Retrospective cohort study of US academic health centers. PLoS One 2024; 19:e0299159. [PMID: 38466710 PMCID: PMC10927125 DOI: 10.1371/journal.pone.0299159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cauda equina syndrome (CES) is a lumbosacral surgical emergency that has been associated with chiropractic spinal manipulation (CSM) in case reports. However, identifying if there is a potential causal effect is complicated by the heightened incidence of CES among those with low back pain (LBP). The study hypothesis was that there would be no increase in the risk of CES in adults with LBP following CSM compared to a propensity-matched cohort following physical therapy (PT) evaluation without spinal manipulation over a three-month follow-up period. METHODS A query of a United States network (TriNetX, Inc.) was conducted, searching health records of more than 107 million patients attending academic health centers, yielding data ranging from 20 years prior to the search date (July 30, 2023). Patients aged 18 or older with LBP were included, excluding those with pre-existing CES, incontinence, or serious pathology that may cause CES. Patients were divided into two cohorts: (1) LBP patients receiving CSM or (2) LBP patients receiving PT evaluation without spinal manipulation. Propensity score matching controlled for confounding variables associated with CES. RESULTS 67,220 patients per cohort (mean age 51 years) remained after propensity matching. CES incidence was 0.07% (95% confidence intervals [CI]: 0.05-0.09%) in the CSM cohort compared to 0.11% (95% CI: 0.09-0.14%) in the PT evaluation cohort, yielding a risk ratio and 95% CI of 0.60 (0.42-0.86; p = .0052). Both cohorts showed a higher rate of CES during the first two weeks of follow-up. CONCLUSIONS These findings suggest that CSM is not a risk factor for CES. Considering prior epidemiologic evidence, patients with LBP may have an elevated risk of CES independent of treatment. These findings warrant further corroboration. In the meantime, clinicians should be vigilant to identify LBP patients with CES and promptly refer them for surgical evaluation.
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Affiliation(s)
- Robert J. Trager
- Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anthony N. Baumann
- Department of Rehabilitation, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
- College of Medicine, Northeast Ohio Medical University, Rootstown, Ohio, United States of America
| | - Jaime A. Perez
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States of America
| | - Jeffery A. Dusek
- Department of Family Medicine and Community Health, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States of America
| | - Romeo-Paolo T. Perfecto
- Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, United States of America
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
| | - Christine M. Goertz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, United States of America
- Duke Clinical Research Institute, Durham, North Carolina, United States of America
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Durham, North Carolina, and Washington, District of Columbia, United States of America
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Zhuang YD, Hu XC, Dai KX, Ye J, Zhang CH, Zhuo WX, Wu JF, Liu SC, Liang ZY, Chen CM. Quantitative anatomical analysis of lumbar interspaces based on 3D CT imaging: optimized segment selection for lumbar puncture in different age groups. Neuroradiology 2024; 66:443-455. [PMID: 38183426 PMCID: PMC10859322 DOI: 10.1007/s00234-023-03272-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND Optimal lumbar puncture segment selection remains controversial. This study aims to analyze anatomical differences among L3-4, L4-5, and L5-S1 segments across age groups and provide quantitative evidence for optimized selection. METHODS 80 cases of CT images were collected with patients aged 10-80 years old. Threedimensional models containing L3-S1 vertebrae, dural sac, and nerve roots were reconstructed. Computer simulation determined the optimal puncture angles for the L3-4, L4-5, and L5-S1 segments. The effective dural sac area (ALDS), traversing nerve root area (ATNR), and area of the lumbar inter-laminar space (ALILS) were measured. Puncture efficacy ratio (ALDS/ALILS) and nerve injury risk ratio (ATNR/ALILS) were calculated. Cases were divided into four groups: A (10-20 years), B (21-40 years), C (41-60 years), and D (61-80 years). Statistical analysis was performed using SPSS. RESULTS 1) ALDS was similar among segments; 2) ATNR was greatest at L5-S1; 3) ALILS was greatest at L5-S1; 4) Puncture efficacy ratio was highest at L3-4 and lowest at L5-S1; 5) Nerve injury risk was highest at L5-S1. In group D, L5-S1 ALDS was larger than L3-4 and L4-5. ALDS decreased after age 40. Age variations were minimal across parameters. CONCLUSION The comprehensive analysis demonstrated L3-4 as the optimal first-choice segment for ages 10-60 years, conferring maximal efficacy and safety. L5-S1 can serve as an alternative option for ages 61-80 years when upper interspaces narrow. This study provides quantitative imaging evidence supporting age-specific, optimized lumbar puncture segment selection.
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Affiliation(s)
- Yuan-Dong Zhuang
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fujian Institute of Neurosurgery, No. 29 Xinquan Rd, Gulou District, Fuzhou, 350001, Fujian, China
| | - Xiao-Cong Hu
- Fujian Medical University, No. 1 Xuefu North Rd, Minhou County, Fuzhou, 350100, Fujian, China
| | - Ke-Xin Dai
- Fujian Medical University, No. 1 Xuefu North Rd, Minhou County, Fuzhou, 350100, Fujian, China
| | - Jun Ye
- Fujian Medical University, No. 1 Xuefu North Rd, Minhou County, Fuzhou, 350100, Fujian, China
| | - Chen-Hui Zhang
- Fujian Medical University, No. 1 Xuefu North Rd, Minhou County, Fuzhou, 350100, Fujian, China
| | - Wen-Xuan Zhuo
- Fujian Medical University, No. 1 Xuefu North Rd, Minhou County, Fuzhou, 350100, Fujian, China
| | - Jian-Feng Wu
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fujian Institute of Neurosurgery, No. 29 Xinquan Rd, Gulou District, Fuzhou, 350001, Fujian, China
| | - Shi-Chao Liu
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fujian Institute of Neurosurgery, No. 29 Xinquan Rd, Gulou District, Fuzhou, 350001, Fujian, China
| | - Ze-Yan Liang
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fujian Institute of Neurosurgery, No. 29 Xinquan Rd, Gulou District, Fuzhou, 350001, Fujian, China
| | - Chun-Mei Chen
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fujian Institute of Neurosurgery, No. 29 Xinquan Rd, Gulou District, Fuzhou, 350001, Fujian, China.
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Huang C, Tang T, Ding Z, Wang H, Zhou Z. Predicting the Probability of Tumor-Specific Survival in Patients Diagnosed With Primary Tumors in the Spinal Cord Using Nomogram Models. Global Spine J 2024:21925682241235894. [PMID: 38406860 DOI: 10.1177/21925682241235894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The goal of this study was to develop a useful clinical prediction nomogram to accurately predict the cancer-specific survival (CSS) of patients with primary spinal cord tumor (SCT), thereby formulating scientific prevention and aiding clinical decision-making. METHODS In this study, patients with SCT diagnoses from the surveillance, epidemiology, and end results (SEER) database (2000-2018) were taken into account. Initially, a nomogram was created using the CSS-associated independent factors that were determined from both univariate and multivariable Cox regression analyses. Furthermore, the nomogram's capacity for calibration, ability to discriminate, and actual clinical effectiveness were assessed through calibration curves, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA), respectively. Finally, a strategy for categorizing SCT patients' risk was developed. RESULTS This study included 909 SCT individuals. A novel nomogram was developed to forecast SCT patients' CSS, taking into account age, histological type, tumor grade, tumor stage, and radiotherapy. These factors were identified as independent prognostic indicators for CSS in SCT patients. Elderly SCT patients with distant metastasis, advanced tumor grade, received radiotherapy, and confirmed lymphoma have a poor prognosis. Meanwhile, the risk classification system could differentiate SCT patients and realize targeted management. CONCLUSIONS The developed nomogram has the ability to accurately forecast the CSS in SCT individuals, aiding in precise decision-making during clinical practice, enhancing health planning, maximizing treatment advantages, and ultimately improving patient prognosis.
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Affiliation(s)
- Chao Huang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Tingting Tang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- School of Nursing, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zichuan Ding
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Haoyang Wang
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Zongke Zhou
- Department of Orthopedics, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Miller J, West J, Khawar H, Middleton R. Cauda equina syndrome. Br J Hosp Med (Lond) 2023; 84:1-7. [PMID: 38186331 DOI: 10.12968/hmed.2023.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Cauda equina syndrome is an uncommon but serious cause of lower back pain resulting from compression of the cauda equina nerve roots, most commonly by lumbar disc herniation. Red flag symptoms, such as bladder dysfunction, saddle anaesthesia and sciatica, should lead to high clinical suspicion of cauda equina syndrome. The British Association of Spinal Surgeons has published an updated standard of care for these patients because of the potentially debilitating effects of missed cases of cauda equina syndrome. This review summarises these standards and provides a framework to support quick triage of at-risk patients. Immediate magnetic resonance imaging, within 1 hour of presentation to the emergency department, is crucial in patients with suspected cauda equina syndrome to allow prompt diagnosis and treatment. Urgent decompressive surgery is usually recommended for the best outcomes, to reduce morbidity and complication rates.
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John A, Simjian T, Lamba N, Yuxin Y, Carosella C, Song J, Trinh S, Lak AM, Mammi M, Zaidi H, Mekary RA. A comparison of the safety and efficacy of minimally invasive surgery versus open surgery in treating cauda equina syndrome: A systematic review and meta-analysis. J Clin Neurosci 2023; 117:98-103. [PMID: 37783070 DOI: 10.1016/j.jocn.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE To compare the safety and efficacy of minimally invasive surgery (MIS) and open surgery (OS) in treating cauda equina syndrome (CES). METHODS A systematic literature search was conducted, searching relevant databases for studies investigating MIS and/or OS in treating CES. Pooled outcomes and their 95% confidence intervals (CIs) were meta-analyzed via random-effects models. RESULTS Ten studies were included in the meta-analysis. Pooled mean operation times were shorter for MIS (75.4 min; 95 %CI: 40.8, 110.0) than OS (155.1 min; 121.3, 188.9). Similarly, mean hospital stay was shorter for MIS (4.08 days; 2.77, 5.39 vs. 8.85 days; 6.56, 11.13). Mean blood loss was smaller for MIS (71.7 mL; 0, 154.5 vs. 366.5; 119.1, 614.0). Mean post-op lumbar/back visual analogue scale (VAS) score was lower for MIS (3.65; 2.75, 4.56 vs. 5.80; 4.55, 7.05). Mean post-op leg VAS score was 1.27 (0.41, 21.4) for MIS and 1.29 (0.47, 2.12) for OS. Mean complete bladder recovery rate was 81.0% (55.0%, 94.0%) for MIS and 75.0% (44.0%, 92.0%) for OS. Mean complete motor recovery rate was larger for MIS (70.0%; 48.0, 85.0 vs. 42.0%; 34.0, 51.0). Mean percentages of "excellent" patient outcomes were equal for MIS (64.0%; 48.0%, 77.0%) and OS (64.0%; 22.0%, 92.0%). CONCLUSION MIS for CES was associated with reduced operative time, length of stay, and blood loss, compared to OS. MIS was also associated with better post-operative lumbar/back and leg VAS scores and complete motor and bladder recovery rates. MIS and OS produced an equal average percentage of "excellent" patient outcomes.
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Affiliation(s)
- Alvin John
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Simjian
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Nayan Lamba
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yao Yuxin
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Claudia Carosella
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Jimin Song
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Stephanie Trinh
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Asad M Lak
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Marco Mammi
- Neurosurgery Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Hasan Zaidi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA.
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Aprato A, Branca Vergano L, Casiraghi A, Liuzza F, Mezzadri U, Balagna A, Prandoni L, Rohayem M, Sacchi L, Smakaj A, Arduini M, Are A, Battiato C, Berlusconi M, Bove F, Cattaneo S, Cavanna M, Chiodini F, Commessatti M, Addevico F, Erasmo R, Ferreli A, Galante C, Giorgi PD, Lamponi F, Moghnie A, Oransky M, Panella A, Pascarella R, Santolini F, Schiro GR, Stella M, Zoccola K, Massé A. Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures. J Orthop Traumatol 2023; 24:46. [PMID: 37665518 PMCID: PMC10477162 DOI: 10.1186/s10195-023-00726-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment. MATERIALS AND METHODS The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment. RESULTS Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated. CONCLUSIONS This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients. LEVEL OF EVIDENCE IV. TRIAL REGISTRATION not applicable (consensus paper).
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Affiliation(s)
- Alessandro Aprato
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy.
| | | | | | | | - Umberto Mezzadri
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | - Alberto Balagna
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
| | | | | | | | | | | | | | | | | | - Federico Bove
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | | | | | | | | | | | - Rocco Erasmo
- Ospedale Civile Santo Spirito di Pescara, Pescara, Italy
| | | | | | | | | | | | - Michel Oransky
- Università degli studi di Roma, ASST degli spedali Civili di Brescia, Brescia, Italy
| | | | | | | | | | | | | | - Alessandro Massé
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
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Lawrence D. Case study highlighting cauda equina syndrome and the effects on bladder management. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2023; 32:S18-S20. [PMID: 37173079 DOI: 10.12968/bjon.2023.32.9.s18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Cauda equina syndrome (CES) is a rare and severe type of spinal stenosis, where all the nerves in the lower back suddenly become severely compressed. It is a serious medical emergency, and compression of the nerves in the lower portion of the spinal canal can lead to permanent loss of bowel and bladder control, paraesthesia, and paralysis of the legs if left untreated. Causes of CES include: trauma, spinal stenosis, herniated discs, spinal tumour, cancerous tumour, inflammatory and infectious conditions or due to an accidental medical intervention. CES patients typically present with symptoms of: saddle anaesthesia, pain, incontinence and numbness. Any of these are red flag symptoms and require immediate investigation and treatment.
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12
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Zhang AS, Xu A, Ansari K, Hardacker K, Anderson G, Alsoof D, Daniels AH. Lumbar Disc Herniation: Diagnosis and Management. Am J Med 2023:S0002-9343(23)00252-8. [PMID: 37072094 DOI: 10.1016/j.amjmed.2023.03.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 04/20/2023]
Abstract
Lumbar disc herniations are common causes of lower back, neurological dysfunction, and buttock/leg pain. Herniation refers to the displacement of the nucleus pulposus of the intervertebral disc through the annulus fibrosus, thereby causing pressure on the neural elements. The sequalae of lumbar disc herniations range in severity from mild low back and buttock pain to severe cases of inability to ambulate and cauda equina syndrome. Diagnosis is achieved with a thorough history and physical along with advanced imaging. Treatment plans are dictated by corresponding patient symptoms and exam findings with their imaging. Most patients can experience relief with non-surgical measures. However, if symptoms persist or worsen, surgery may be appropriate.
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Affiliation(s)
- Andrew S Zhang
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA; Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Andrew Xu
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Kashif Ansari
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Kyle Hardacker
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - George Anderson
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Daniel Alsoof
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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13
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Hawa A, Denasty A, Elmobdy K, Mesfin A. The Most Impactful Articles on Cauda Equina Syndrome. Cureus 2023; 15:e38069. [PMID: 37228568 PMCID: PMC10208163 DOI: 10.7759/cureus.38069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Cauda equina syndrome (CES) is an uncommon condition that can lead to permanent neurological deficits if not diagnosed and addressed promptly. Varying prognoses, including retropulsed fracture fragments, disc herniations, and epidural abscesses, can result in CES. Our objective was to identify the top 50 most impactful articles on CES and analyze the characteristics of these publications. In August of 2021, we used the Web of Science Core Collection bibliographic database to query the phrase "cauda equina syndrome." Articles between 1900 and 2021 were included in the search, and these articles were ranked based on the number of citations. The following variables were recorded: title, first author, journal, year of publication, number of citations, country of origin, the institution of publication, and topic of the paper. A total of 2096 articles matched the search criteria. The top 50 most impactful articles ranged from 43 to 439 in their number of citations. All articles on the list were published in English, with the year of publication ranging from 1938 to 2014. The United States accounted for the greatest number of articles published at 27. The medical journal Spine accounted for the greatest number of publications at nine. And the 2000s was the decade with the most cited articles. It is generally acknowledged that the clinical signals for CES are diverse with no predictive value on patient outcomes. Similar uncertainty exists in the etiology of the condition, though CES induced by spinal anesthesia is a factor of particular interest. Additionally, it is generally recognized that delayed diagnosis of the condition often results in permanent neurological deficits. Identification of the most impactful articles on CES is critical in drawing attention to this significant condition.
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Affiliation(s)
- Aasim Hawa
- Orthopedics, University of Rochester Medical Center, Rochester, USA
| | - Adwin Denasty
- Orthopedics, University of Rochester Medical Center, Rochester, USA
| | - Karim Elmobdy
- Orthopedics, University of Rochester Medical Center, Rochester, USA
| | - Addisu Mesfin
- Orthopedics, University of Rochester Medical Center, Rochester, USA
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14
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Byvaltsev VA, Kalinin AA, Shepelev VV, Pestryakov YY, Jubaeva BA. Minimally invasive decompression alone versus fusion surgery for acute lumbar disk herniation combined incomplete cauda equina syndrome. Clin Neurol Neurosurg 2023; 225:107589. [PMID: 36640736 DOI: 10.1016/j.clineuro.2023.107589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 01/02/2023] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Abstract
STUDY DESIGN Retrospective single center study. BACKGROUND Cauda equine syndrome (CES), which caused by acute lumbar disc herniation (LDH), often requires urgent surgical treatment. Currently, there is no standard defining the type of surgery, and approaches to the treatment of patients are based on the experience of the surgeon. PURPOSE to compare the clinical efficacy of minimally invasive decompression alone (Decompression alone group) and transforaminal lumbar interbody fusion (Fusion group) in the treatment of the incomplete CES, caused by acute LDH. PATIENTS AND METHODS 89 patients with acute incomplete CES associated with LDH either underwent decompression alone and fusion surgery from January 2005 to January 2020 in single-center, and data were collected and retrospectively analyzed. The patients were divided into 2 groups according to the operation technics: the Decompression alone group (n = 46) and the Fusion group (n = 43). The perioperative clinical data (neurological deficit, control of the urinary bladder sphincter, ODI scale, SF-36) was used to assess the efficacy of the respective surgical methods before operation and with a minimum follow-up 24 months. RESULTS Verified statistical significance more bleeding, longer surgery time and hospital stay, in the Fusion group than in the Decompression alone group. The postoperative clinical data dramatic improved after Decompression alone and Fusion surgery. At early postoperative period registered better clinical outcomes according to ODI, SF-36 after Decompression alone surgery, but at minimum follow-up 24 months verified better in the Fusion group. The number of revision interventions in the Decompression alone group was 28.3% (n = 13), in Fusion group - 9.3% (n = 4) (p = 0.02). CONCLUSIONS The prevalence of acute incomplete CES due to LDH in our series was registered in 1.02% of patients (124 of 12087). In the Fusion group, in the long-term period, there were better clinical outcomes and fewer revision surgical interventions compared with Decompression alone.
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Affiliation(s)
- Vadim A Byvaltsev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia; Department of Neurosurgery, Railway Clinical Hospital, Irkutsk, Russia; Department of Traumatology, Orthopedic and Neurosurgery, Irkutsk State Medical Academy of Postgraduate Education, Irkutsk, Russia.
| | - Andrei A Kalinin
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia; Department of Neurosurgery, Railway Clinical Hospital, Irkutsk, Russia.
| | - Valerii V Shepelev
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia.
| | - Yurii Ya Pestryakov
- Department of Neurosurgery, Irkutsk State Medical University, Irkutsk, Russia.
| | - Bagdat A Jubaeva
- Department of Neurosurgery, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan.
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15
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Taghlabi KM, Bhenderu LS, Guerrero JR, Sulhan S, Jenson AV, Cruz-Garza JG, Faraji AH. Acute aortic occlusion leading to spinal cord ischemia in a 73-year-old: A case report. Surg Neurol Int 2022; 13:581. [PMID: 36600757 PMCID: PMC9805641 DOI: 10.25259/sni_898_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
Background Cauda equina syndrome (CES) is typically caused by a compressive etiology from a herniated disk, tumor, or fracture of the spine compressing the thecal sac. Here, we report a CES mimic - acute aortic occlusion (AAO), a rare disease that is associated with high morbidity and mortality. AAO can compromise spinal cord blood supply and leads to spinal cord ischemia. Case Description Our patient presented with an acute onset of bilateral lower extremity pain and weakness with bowel/bladder incontinence, a constellation of symptoms concerning for CES. However, on initial imaging, there was no compression of his thecal sac to explain his symptomology. Further, investigation revealed an AAO. The patient underwent an emergent aortic thrombectomy with resolution of symptoms. Conclusion AAO can mimic CES and should be considered in one's differential diagnosis when imaging is negative for any spinal compressive etiologies.
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Affiliation(s)
- Khaled M. Taghlabi
- Corresponding author: Khaled M. Taghlabi, Department of Neurological Surgery, Houston Methodist Hospital, Houston, United States.
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Topolovec M, Faganeli N, Brumat P. Case Report: Campylobacter fetus caused pyogenic spondylodiscitis with a presentation of cauda equina syndrome after instrumented lumbar fusion surgery. Front Surg 2022; 9:998011. [PMID: 36268208 PMCID: PMC9577107 DOI: 10.3389/fsurg.2022.998011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/12/2022] [Indexed: 11/07/2022] Open
Abstract
Spondylodiscitis with/without neurologic impairment is a serious infection, predominantly occurring in high-risk patients. Campylobacter fetus caused spondylodiscitis is very rare. Evidence-based therapeutic concepts for lumbar spondylodiscitis are lacking. A 64-year-old high-risk woman underwent decompression with instrumented lumbar fusion. Six months after index surgery, she developed pyelonephritis, which deteriorated to sepsis and presentation of cauda equina syndrome. She underwent urgent revision with decompression, debridement, and instrumentation removal, and received long-term antibiotics. Culture grew Campylobacter fetus, previously not reported as a cause of spondylodiscitis after elective instrumented lumbar fusion. Emergent debridement and removal of instrumentation, with 2 months of targeted intravenous antibiotics followed by 6 weeks of oral antibiotics led to complete spondylodiscitis resolution. Prompt diagnostics and targeted antibiotic treatment are paramount when dealing with spinal infections, particularly in patients with rare causative pathogens like Campylobacter fetus. Concomitant neurological complications may require emergent surgical management in the case of cauda equina syndrome.
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Affiliation(s)
- Matevž Topolovec
- Department of Spine Surgery, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Nataša Faganeli
- Department of Spine Surgery, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia
| | - Peter Brumat
- Department of Spine Surgery, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia,Correspondence: Peter Brumat
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Epstein NE. Review/Perspective: Operations for Cauda Equina Syndromes - “The Sooner the Better”. Surg Neurol Int 2022; 13:100. [PMID: 35399881 PMCID: PMC8986648 DOI: 10.25259/sni_170_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Although most studies recommended that early surgery for cauda equina syndromes (CES) be performed within <48 h., the largest and most comprehensive Nationwide Inpatient Sample Database (NISC) series, involving over 25,000 CES patients recommended that time be shortened to 0–<24 h. In short, CES surgery performed “the sooner the better,” was best. Methods: The 2 major variants of CES include; incomplete/partial ICES, and those with urinary retention/bowel incontinence (RCES). Those with ICES often exhibit varying combinations of motor weakness, sensory loss (i.e. including perineal numbness), and urinary dysfunction, while RCES patients typically exhibit more severe paraparesis, sensory loss including saddle anesthesia, and urinary/bowel incontinence. The pathology responsible for ICES/RCES syndromes may include; acute disc herniations/stenosis, trauma (i.e. including iatrogenic/ surgical hematomas etc.), infections, abscesses, and other pathology. Surgery for either ICES/RCES may include decompressions to multilevel laminectomies/fusions. Results: Following early surgery, most studies showed that ICES and RCES patients exhibited improvement in motor weakness and sensory loss. However, recovery of sphincter function was more variable, being poorer for RCES patients with preoperative urinary retention/bowel incontinence. Conclusions: Although early CES surgery was defined in most studies as <48 h., two large NISC series involving over 25, 000 CES patients showed that CES surgery performed within 0 -< 24 h resulted in the best outcomes.
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18
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Bowel and Bladder Care in Patients With Spinal Cord Injury. J Am Acad Orthop Surg 2022; 30:263-272. [PMID: 34932503 DOI: 10.5435/jaaos-d-21-00873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/21/2021] [Indexed: 02/01/2023] Open
Abstract
Complete and incomplete spinal cord injuries affect between 250,000 and 500,000 people on an annual basis worldwide. In addition to sensory and motor dysfunction, spinal cord injury patients also suffer from associated conditions such as neurogenic bowel and bladder dysfunction. The degree of dysfunction varies on the level, degree, and type of spinal cord injury that occurs. In addition to the acute surgical treatment of these patients, spine surgeons should understand how to manage neurogenic bowel and bladder care on both a short- and long-term basis to minimize the risk for complications and optimize potential for rehabilitation.
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