Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome

Cauda Equina Syndrome: Cost Burden After Spinal Decompression

STUDY DESIGN

Observational cohort study.

OBJECTIVE

Cauda equina syndrome (CES) is a rare neurologic condition with potentially devastating consequences. The objective of this study was to compare the 2-year postoperative cost-associated treatments after posterior spinal decompression between patients with and without CES.

METHODS

By analyzing a commercial insurance claims database, patients who underwent posterior spinal decompression with a concurrent diagnosis of lumbar spinal stenosis, radiculopathy, or disk herniation in 2017 were identified and included in the study. The primary outcome was the cost of payments for identified treatments in the 2-year period after surgery. Treatments included were (1) physical therapy (PT), (2) pain medication, (3) injections, (4) bladder management, (5) bowel management, (6) sexual dysfunction treatment, and (7) psychological treatment.

RESULTS

In total, 3,140 patients (age, 55.3 ± 12.0 years; male, 62.2%) were included in the study. The average total cost of treatments identified was $2,996 ± 6,368 per patient. The overall cost of identified procedures was $2,969 ± 6,356 in non-CES patients, compared with $4,535 ± 6,898 in patients with CES ( P = 0.079). Among identified treatments, only PT and bladder management costs were significantly higher for patients with CES (PT: +115%, P < 0.001; bladder management: +697%, P < 0.001). The difference in overall cost was significant between patients (non-CES: $1,824 ± 3,667; CES: $3,022 ± 4,679; P = 0.020) in the first year. No difference was found in the second year.

DISCUSSION

A short-term difference was observed in costs occurring in the first postoperative year. Cost of treatments was similar between patients apart from PT and bladder management.

How to assess the long-term recovery outcomes of patients with cauda equina syndrome before surgery: a retrospective cohort study

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.

A rare case of spontaneous giant pneumorrachis presenting with cauda equina syndrome: a case report

INTRODUCTION

Pneumorrachis is presence of air in the epidural space. It could be the result of trauma, barotrauma, iatrogenic or spontaneous. The pneumorrachis per se is an underdiagnosed entity as most of the patients are asymptomatic or have subclinical symptoms. The spontaneous occurrence of pneumorrachis has been reported in literature but giant spontaneous occurrence causing cauda equina syndrome has not been reported so far.

CASE PRESENTATION

We report a case of 56-year-old male patient who came to our OPD on wheelchair with complains of difficulty in walking for 6 months with dribbling of urine for 2 months with on and off back pain. His perianal sensation was reduced with absent voluntary anal contraction. Imaging revealed giant air pockets in the spinal canal of L5-S1 extending upto L4-L5. It was managed surgically wherein laminectomy without fusion was done. The patient responded well to the treatment.

DISCUSSION

There are many causes of pneumorrachis described in literature. Most of the cases of pneumorrachis are asymptomatic and incidentally diagnosed. With the improvement in radio-diagnostic modalities, the diagnosis of pneumorrachis can be easily established. When symptomatic, they can be managed conservatively. Those presenting with neurological deficit may require surgical intervention or other invasive intervention.

Chronic cauda equina syndrome decompression surgery recovery is very "bad"? Based on patient self-assessment

BACKGROUND

Symptoms of cauda equina syndrome (CES) secondary to degenerative lumbar spine diseases are sometimes mild and tend to be ignored by patients, resulting in delayed treatment. In addition, the long-term efficacy of surgery is unclear.

OBJECTIVE

To determine the predictive factors of CES and post-operative recovery in patients with symptoms lasting > 3 months.

METHODS

From January 2011 to December 2020, data of 45 patients with CES secondary to lumbar disk herniation/lumbar spinal stenosis were collected from a single center. The patients had bladder, bowel or sexual dysfunction and decreased perineal sensation that lasted for > 3 months. A 2-year post-operative follow-up was conducted to evaluate recovery outcomes, which were measured by validated self-assessment questionnaires conducted by telephone and online.

RESULTS

Overall, 45 CES patients (57.8% female; mean age, 56 years) were included. The duration of pre-operative CES symptoms was 79.6 weeks (range, 13-730 weeks). The incidence of saddle anesthesia before decompression was 71.1% (n = 32), bladder dysfunction 84.4% (n = 38), bowel dysfunction 62.2% (n = 28) and sexual dysfunction 64.4% (n = 29). The overall recovery rate of CES after a 2-year follow-up was 64.4%. The rates of the residual symptoms at the last follow-up were as follows: saddle anesthesia 22.2%, bladder dysfunction 33.3%, bowel dysfunction 24.4% and sexual dysfunction 48.9%. Pre-operative saddle anesthesia, overactive bladder and sexual dysfunction were risk factors for poor prognosis after decompression.

CONCLUSION

CES patients with symptoms lasting > 3 months may recover after surgery. Sexual dysfunction has a high residual rate and should not be ignored during diagnosis and treatment.

The Reoperation, Readmission, and Complication Rates at 30 Days Following Lumbar Decompression for Cauda Equina Syndrome

Background and objective Cauda equina syndrome (CES) is considered a surgical emergency, and its primary treatment involves decompression of the nerve roots, typically in the form of discectomy or laminectomy. The primary aim of this study was to determine the complication, reoperation, and readmission rates within 30 days of surgical treatment of CES secondary to disc herniation by using the PearlDiver database (PearlDiver Technologies, Colorado Springs, CO). The secondary aim was to assess preoperative risk factors for a higher likelihood of complication occurrence within 30 days of surgery for CES. Methods A total of 524 patients who had undergone lumbar discectomy or laminectomy for CES were identified. The outcome measures were 30-day reoperation rate for revision decompression or lumbar fusion, and 30-day readmissions related to surgery. The patient data collected included medical history and surgical data including the number of levels of discectomy and laminectomy. Results Based on our findings, intraoperative dural tears, valvular heart disease, and fluid and electrolyte abnormalities were significant risk factors for readmission to the hospital within 30 days following surgery for CES. The most common postoperative complications were as follows: visits to the emergency department (63 patients, 12%), surgical site infection (21 patients, 4%), urinary tract infection (14 patients, 3%), and postoperative anemia (11 patients, 2%). Conclusions In the 30-day period following lumbar decompression for cauda equina syndrome, our findings demonstrated an 8% reoperation rate and 17% readmission rate. Although CES is considered an indication for urgent surgery, gaining awareness about reoperation, readmission, and complication rates in the immediate postoperative period may help calibrate expectations and inform medical decision-making.

Characteristics and clinical features of cauda equina syndrome: insights from a study on 256 patients

OBJECTIVE

To determine the frequency, clinical presentation, and etiological factors of cauda equina syndrome (CES).

MATERIALS AND METHOD

This retrospective study was done on 256 participants, and aimed to analyze the frequency and patterns of clinical presentation in suspected cases of CES. The inclusion criteria included participants aged 18 or older with medical records available for review and having red-flagged symptoms for CES. The study collected information on various factors such as age, gender, confirmation of CES on MRI, neurological deficits, etiological factors, duration of symptoms, and more. The data collected was analyzed using descriptive statistics and logistic regression to identify significant variables between MRI-proven CES and suspected CES.

RESULTS

The mean age was 58.05 ± 19.26 years, with 151 females (58.98%) and 105 males (41.02%). The majority (50.78%) had a neurological deficit, while other symptoms included difficulty initiating micturition or impaired sensation of urinary flow (17.58%), loss of sensation of rectal fullness (3.12%), urinary or faecal incontinence (35.16%), bilateral sciatica (21.88%), neurological symptoms in the lower limbs (25.00%), anaesthesia or any leg weakness (24.22%), and bilateral sciatica as the predominant symptom (21.88%). Symptoms were chronic in 47.27% and acute in 21.88%. The odds of MRI-proven CES increase by 3% per year of age. Neurological deficit was strongly associated with MRI-proven CES (OR = 14.97), while loss of sensation of rectal fullness increased the odds by 10-fold (OR = 10.62).

CONCLUSION

CES can present with various symptoms, including the bilateral neurological deficit, urinary and faecal incontinence, and bilateral sciatica, with age, severe bilateral neurological deficit, and loss of sensation of rectal fullness being associated with MRI-proven CES. Early diagnosis and treatment are crucial for better outcomes.

The Most Impactful Articles on Cauda Equina Syndrome

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.

Presentation, management, and outcomes of cauda equina syndrome up to one year after surgery, using clinician and participant reporting: A multi-centre prospective cohort study

Background

Cauda equina syndrome (CES) results from nerve root compression in the lumbosacral spine, usually due to a prolapsed intervertebral disc. Evidence for management of CES is limited by its infrequent occurrence and lack of standardised clinical definitions and outcome measures.

Methods

This is a prospective multi-centre observational cohort study of adults with CES in the UK. We assessed presentation, investigation, management, and all Core Outcome Set domains up to one year post-operatively using clinician and participant reporting. Univariable and multivariable associations with the Oswestry Disability Index (ODI) and urinary outcomes were investigated.

Findings

In 621 participants with CES, catheterisation for urinary retention was required pre-operatively in 31% (191/615). At discharge, only 13% (78/616) required a catheter. Median time to surgery from symptom onset was 3 days (IQR:1–8) with 32% (175/545) undergoing surgery within 48 h. Earlier surgery was associated with catheterisation (OR:2.2, 95%CI:1.5–3.3) but not with admission ODI or radiological compression. In multivariable analyses catheter requirement at discharge was associated with pre-operative catheterisation (OR:10.6, 95%CI:5.8–20.4) and one-year ODI was associated with presentation ODI (r = 0.3, 95%CI:0.2–0.4), but neither outcome was associated with time to surgery or radiological compression. Additional healthcare services were required by 65% (320/490) during one year follow up.

Interpretation

Post-operative functional improvement occurred even in those presenting with urinary retention. There was no association between outcomes and time to surgery in this observational study. Significant healthcare needs remained post-operatively.

Funding

DCN Endowment Fund funded study administration. Castor EDC provided database use. No other study funding was received.

Rates of Future Lumbar Fusion in Patients with Cauda Equina Syndrome Treated With Decompression

INTRODUCTION

The long-term risk of conversion to lumbar fusion is ill-defined for patients with cauda equina syndrome (CES) treated with decompression. This study aimed to identify the rates of fusion in patients with CES and compare those rates with a matched lumbar spinal stenosis (LSS) group.

METHODS

Patients with CES who underwent decompression were identified in a national database and matched to control patients with LSS. The rates of conversion to fusion were identified and compared. Multivariate logistic regression analysis identified independently associated risk factors. A subanalysis was conducted after stratifying by timing between CES diagnosis and decompression.

RESULTS

The rate of lumbar fusion in the CES cohort was 3.6% after 1 year, 6.7% after 3 years, and 7.8% after 5 years, significantly higher than the LSS control group at all time points (1 year: 1.6%, P = 0.001; 3 years: 3.0%, P &lt; 0.001; 5 years: 3.8%, P &lt; 0.001). CES was independently associated with increased risk of conversion to fusion (odds ratio: 2.13; 95% confidence interval: 1.56 to 2.97; P &lt; 0.001). Surgical timing was not associated with risk of conversion to fusion.

CONCLUSIONS

After 5 years, 7.8% of patients with CES underwent fusion, a markedly higher rate compared with patients with LSS. Counseling patients with CES on this increased risk of future surgery is important for patient education and satisfaction.

Minimally invasive discectomy versus open laminectomy and discectomy for the treatment of cauda equina syndrome: A preliminary study and case series

Background

Cauda Equina syndrome (CES) is a potentially devastating condition and is treated usually with urgent open surgical decompression of the spinal canal. Currently, the role of minimally invasive discectomy (MID) as an alternative surgical technique for CES is unclear.

Objective

The purpose of this study was to compare clinical outcomes following MID and open laminectomy and discectomy for the treatment of CES.

Methods

The study cohort included patients that underwent surgery due to CES at our institute. Patients' outcomes included: surgical complications, length of hospitalization, postoperative lower extremity motor score (LEMS), Numerical Rating Scale (NRS) for leg and back pain, Oswestry disability index (ODI), and the EQ-5D health-related quality of life questionnaire.

Results

Twelve patients underwent MID and 12 underwent open laminectomy and discectomy. Complications and revisions rates were comparable between the groups. Postoperative urine incontinence and saddle dysesthesia improved in 50% of patients in both groups. LEMS improved from 47.08 ± 5.4 to 49.27 ± 0.9 in the MID group and from 44.46 ± 5.9 to 49.0 ± 1.4 in the open group. Although, leg pain improved in both groups from 8.4 ± 2.4 to 3 ± 2.1 in the MID and from 8.44 ± 3.3 to 3.88 ± 3 in the open group, significant improvement in back pain was found only in the MID group. Final functional scores were similar between groups.

Conclusions

Our preliminary results suggest that minimally invasive discectomy is an effective and safe procedure for the treatment of CES when compared to open laminectomy and discectomy. However, MID in these cases should only be considered by surgeons experienced in minimally invasive spine surgery. Further studies with bigger sample sizes and long-term follow-ups are needed.

Role of Invasive Urodynamic Studies in Establishing Cauda Equina Syndrome and Postoperative Recovery

STUDY DESIGN

Retrospective with prospective follow-up.

OBJECTIVE

Confirming the diagnosis of CES based purely on symptoms and signs is unreliable and usually associated with high false positive rate. A missed diagnosis can permanently disable the patient. Present study aims to determine the relationship between clinical symptoms/ signs (bladder dysfunction) with UDS, subsequently aid in surgical decision making and assessing post-operative recovery.

METHODS

A prospective follow-up of patients with disc herniation and bladder symptoms from January 2018 to July 2020 was done. All patients underwent UDS and grouped into acontractile, hypocontractile and normal bladder. Data regarding PAS, VAC, GTP, timing to surgery and onset of radiculopathy and recovery with correlation to UDS was done preoperatively and post operatively.

RESULTS

107 patients were studied (M-63/F-44). Patients with PAS present still had acontractile (61%) or hypocontractile (39%) detrusor and with VAC present, 57% had acontractile and 43% hypocontractile detrusors. 10 patients with both PAS and VAC present had acontractile detrusor. 82% patients with acute radiculopathy (<2 days) improved when operated <24 hrs while only 47% showed improvement with chronic radiculopathy. The detrusor function recovered in 66.1% when operated <12 hours, 40% in <12-24 hours of presentation.

CONCLUSION

Adjuvant information from UDS in combination with clinicoradiological findings help in accurate diagnosis even in patients with no objective motor and sensory deficits. Quantitative findings on UDS are consistent with postoperative recovery of patient's urination power, representing improvement and can be used as a prognostic factor.

Cauda Equina Syndrome: Poor Recovery Prognosis Despite Early Treatment

STUDY DESIGN

A prospective patient's database operated on a cauda equina syndrome (CES).

OBJECTIVE

The aim of our study was to identify prognosis factors for favorable functional recovery after CES.

SUMMARY OF BACKGROUND DATA

CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery.

METHODS

One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted.

RESULTS

The patients were young with a median age of 46.8 years (range 18-86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery.

CONCLUSION

CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.Level of Evidence: 4.

Is Cauda Equina Surgery Safe Out-of-Hours? A Single United Kingdom Institute Experience

BACKGROUND

Cauda equina syndrome (CES) can have devastating neurological sequelae if surgical treatment is delayed. However, out-of-hours surgery (weekdays from 6:00 pm to 8:00 am and all weekend operations) can potentially result in higher rates of intraoperative complications, resulting in worse outcomes. In the present study, we have described our outcomes for patients with CES during an 8-year period (December 2011 to October 2019) with the aim of assessing the risk of out-of-hours surgery.

METHODS

We performed a retrospective analysis of inpatient events and outcomes at 6 months of follow-up. Patient demographics, symptoms, and management data were extracted, and a risk factor analysis was performed using logistic regression. The outcome measures were the incidence of complications and symptom changes at follow-up. Symptom outcome changes between 2 time points were analyzed using repeated measures.

RESULTS

A total of 278 patients were included in the present study. Surgery out-of-hours (P = 0.018) and prolonged operations (P = 0.018) were significant risk factors for intraoperative complications. Improved outcomes at 6 months of follow-up were found for lower back pain, sciatica, altered saddle sensation, and urinary sphincter disturbance, with no significant changes for the remaining symptoms. Out-of-hours surgeries did not significantly affect individual symptom outcomes.

CONCLUSIONS

Our analysis has suggested that emergency decompressive surgery for patients with CES does not result in worsening of outcomes with out-of-hours surgery compared with in-hours. However, our findings also showed that no clear benefit exists to expediting surgery for those with severe presentations. Thus, decompressive surgery should be undertaken at the earliest possible time to safely do so.

Evaluation and Management of Cauda Equina Syndrome

Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.

Outcomes of cauda equina syndrome due to lumbar disc herniation after surgical management and the factors affecting it: a systematic review and meta-analysis of 22 studies with 852 cases

PURPOSE

This study aimed to investigate the long-term clinical outcomes after surgical decompression in cauda equina syndrome (CES) and see if any preoperative patient-related factors contributed to this outcome.

METHODS

A systematic literature search was conducted in the electronic databases of PubMed, Embase, Scopus, and Ovid. Data regarding outcome parameters from eligible studies were extracted. Meta-analysis was performed using a random-effect model.

RESULTS

A total of 852 patients (492 males and 360 females), with a mean age of 44.6 ± 5.5 years from 22 studies diagnosed with cauda equina syndrome and undergoing surgical decompression, were included in the meta-analysis; however, not all studies reported every outcome. The mean follow-up period was 39.2 months, with a minimum follow-up of 12 months in all included studies. Meta-analysis showed that on long-term follow-up, 43.3% [29.1, 57.5] (n=708) of patients had persistent bladder dysfunction. Persistent bowel dysfunction was observed in 31.1% [14.7, 47.6] (n=439) cases, sensory deficit in 53.3% [37.1, 69.6] (n=519), motor weakness in 38.4% [22.4, 54.4] (n=490), and sexual dysfunction in 40.1% [28.0, 52.1] (n=411). Decompression within 48 hours of the onset of symptoms was associated with a favourable outcome in terms of bladder function with 24.6% [1.6, 50.9] (n=75) patients having persistent dysfunction, whereas 50.3% [10.3, 90.4] (n=185) of patients in studies with a mean time to decompression after 48 hours had persistent bladder dysfunction. Other factors such as speed of onset and sex of the patients were not found to significantly impact long-term bladder outcomes.

CONCLUSION

The long-term outcomes of CES after decompression are enumerated. Decompression within 48 hours of the onset of symptoms appears to result in fewer patients with persistent bladder dysfunction. However, a randomized controlled trial is required to conclusively determine whether early decompression leads to better outcomes.

Long-term core outcomes in cauda equina syndrome

AIMS

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

METHODS

Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires.

RESULTS

In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR.

CONCLUSION

This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464-1471.

Long-term mental wellbeing and functioning after surgery for cauda equina syndrome

Introduction

Cauda Equina Syndrome (CES) can cause persisting life-changing dysfunction. There is scarce literature regarding the long-term assessment of CES symptoms, and rarer still is the impact of these symptoms on mental wellbeing investigated. This study assessed the long-term patient reported mental wellbeing outcomes of post-operative CES patients.

Methods

Patients who underwent surgery for CES between August 2013 and November 2014 were identified using an ethically approved database. They then completed validated questionnaires over the telephone assessing their mental and physical functioning (Short-Form 12 Questionnaire), generating the Physical Component Summary (PCS) and Mental Component Summary (MCS). Bladder, bowel and sexual function were also assessed using validated questionnaires. MCS scores were compared to both the Scottish mean and previously published cut-offs indicating patients at risk of depression. Correlations of MCS with bladder, bowel, sexual and physical dysfunction were examined and multifactorial regression to predict MCS from these variables analysed. Independent t-tests assessed the mean difference in MCS between patients presenting with incomplete CES (CES-I) and CES with retention (CES-R) and between those with radiologically confirmed and impending CES.

Results

Forty-six participants with a mean follow-up time of 43 months completed the study. The mean (±SD) MCS was 49 (±11.8) with 22% demonstrating poor mental health related quality of life in comparison to the Scottish mean. Overall, 37% had scores consistent with being at risk for depression with in the last 30 days, and 45% within the last 12 months. MCS was significantly correlated with Urinary Symptoms Profile (USP) score (-0.608), NBDS score (-0.556), ASEX score (-0.349) and PCS score (0.413) with worse bladder, bowel, sexual and physical dysfunction associated with worse MCS score. Multifactorial regression analysis demonstrated both urinary (USP score p = 0.031) and bowel function (NBDS score p = 0.009) to be significant predictive variables of mental health related quality of life. There were no significant mean differences in MCS between those presenting with CES-I and CES-R or those with radiologically complete and impending CES.

Discussion

This study demonstrates a high frequency of being at risk for depression in patients with CES and identifies outcome measures (physical, sexual and more so bladder and bowel dysfunction) associated with poorer mental wellbeing. Our large cohort and long follow-up highlight that CES patients should be considered at risk of depression, and the need to consider mental health outcomes following CES surgery.

Long-term rates of bladder dysfunction after decompression in patients with cauda equina syndrome

BACKGROUND CONTEXT

Cauda equina syndrome (CES) occurs due to compression of the lumbar and sacral nerve roots and is considered a surgical emergency. Although the condition is relatively rare, the associated morbidity can be devastating to patients. While substantial research has been conducted on the timing of treatment, the literature regarding long-term rates of bladder dysfunction in CES patients is scarce.

PURPOSE

The aim of this study was to identify long-term rates of bladder dysfunction in CES patients and to compare those rates to non-CES patients who underwent similar spinal decompression.

STUDY DESIGN/SETTING

Retrospective database study.

PATIENT SAMPLE

The CES cohort was comprised of 2,362 patients who underwent decompression surgery following CES diagnosis with a 5-year follow-up. These patients were matched to 9,448 non-CES control patients who underwent spinal decompression without a diagnosis of CES.

OUTCOME MEASURES

Diagnosis of bladder dysfunction, surgical procedure to address bladder dysfunction METHODS: Using the national insurance claims database, PearlDiver, CES patients who underwent decompression surgery were identified and 1:4 matched to non-CES patients who underwent similar spinal decompression surgery. The 1-year, 3-year, and 5-year rates of progression to a bladder dysfunction diagnosis and surgical intervention to manage bladder dysfunction were recorded. The CES and non-CES groups were compared with univariate testing, and an analysis of risk factors for bladder dysfunction was performed with multivariate logistic regression analysis.

RESULTS

A total of 2,362 CES patients who underwent decompression surgery were identified and matched to 9,448 non-CES control patients. After 5 years, CES patients had a 10%-12% increased absolute risk of continued bladder dysfunction and a 0.7%-0.9% increased absolute risk of undergoing a surgical procedure for bladder dysfunction, as compared to matched non-CES patients. Multivariate analysis controlling for age, sex, obesity, tobacco use, and diabetes, identified CES as independently associated with increased 5-year risk for bladder dysfunction diagnosis (odds ratio [OR]: 1.72; 95% confidence interaval [CI] 1.56-1.89; p<.001) and procedure (OR: 1.40; 95% CI 1.07-1.81; p=.012).

CONCLUSIONS

Understanding the long-term risk for bladder dysfunction in CES patients is important for the future care and counseling of patients. Compared to non-CES patients who underwent similar spinal decompression, CES patients were observed to have a significantly higher long-term likelihood for both bladder dysfunction diagnosis and urologic surgical procedure.

Neurogenic Bowel Dysfunction in Children and Adolescents

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Full Endoscopic Lumbar Discectomy Versus Laminectomy for Cauda Equina Syndrome

BACKGROUND

Typically, open surgery is advocated for cauda equina patients. The goal of this study was to compare the clinical efficacy of full endoscopic lumbar discectomy and laminectomy in the treatment of cauda equina syndrome (CES) caused by lumbar disc herniation.

METHODS

Forty-three patients with CES either underwent endoscopic or laminectomy surgery from May 2015 to April 2016, and data were collected and retrospectively analyzed. The patients were divided into 2 groups according to the surgical methods: the endoscopy group (with 21 patients, 14 males and 7 females, and an average age of 42.67 with a standard deviation of 9.70 years) and the laminectomy group (with 22 patients, 16 males and 6 females, and an average age of 44.55 with a standard deviation of 9.36 years). The modified Japanese Orthopaedic Association (JOA) "leg-trunk-bladder" score was used to assess the efficacy of the respective surgical methods.

RESULTS

Analysis showed longer surgery time, more bleeding, and longer hospital stay in the laminectomy group than in the endoscopy group with statistical significance. The postoperative JOA scores improved in both groups when compared with those before the operation, and the differences were statistically significant. There were no significant differences in JOA scores between the 2 groups at preoperation and 6-month and 1-year follow-ups. There was 1 patient in each group whose CES symptoms worsened after endoscopy. However, immediate reoperation resulted in satisfactory outcomes.

CONCLUSIONS

CES clinical symptom resolution was equal with endoscopy and laminectomy both in short-term and midterm follow-up. However, endoscopic treatment was advantageous by reducing the amount of bleeding, duration of surgery, and hospitalization days when compared to laminectomy.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Feasibility study Endoscopic Decompression for Cauda Equina.

Does surgical decompression alleviate neglected cauda equina syndromes attributed to lumbar disc herniation and/or degenerative canal stenosis?

Background:

Most studies recommend urgent decompression (e.g., within 48–72 h) of the symptomatic onset of a cauda equina syndrome. As patients in our area typically underwent >3 months delayed surgery for cauda equina syndromes due to disc disease/stenosis, we asked whether surgery was still worthwhile.

Methods:

This was a retrospective analysis of 12 patients (2012–2018) who underwent delayed surgical decompression for cauda equina syndromes secondary to lumbar disc herniations and/or degenerative lumbar canal stenosis.

Results:

After a mean postoperative duration of 8.22 months, nine patients experienced the complete restoration of bladder status; two patients required intermittent self-catheterization, while one patient had some residual symptoms (e.g., urgency but able to void with some difficulty).

Conclusion:

For 12 patients who originally presented with cauda equina syndrome with complete incontinence, nine exhibited delayed full recovery of bladder function with average of 8.22 months postoperatively. We would, therefore, advise that delayed surgical decompression be offered to these patients, irrespective of the preoperative duration of cauda equina syndromes with complete incontinence.

Sexual and Bladder Dysfunction in Cauda Equina Syndrome: Correlation with Clinical and Urodynamic Studies

Study Design

Retrospective cohort study.

Purpose

To analyze the clinical and sphincteric outcomes and the extent of sexual dysfunction (SD) in subjects with cauda equina syndrome (CES) and to assess their correlation with patient-reported and clinical/urodynamic parameters.

Overview of Literature

Despite vast literature present for CES, extent of the problem of SD in CES patients has not received enough attention as reflected by the limited information in literature. Little is known about exact prevalence at presentation or about the recovery. A better understanding of SD and bladder dysfunction in CES secondary to lumbar disc herniation is essential as it commonly occurs in the sexually active age group.

Methods

All cases of cauda equine syndrome secondary to lumbar disc herniation were recruited. Biographical and clinical data, history, examination findings, operative variables, recovery, and SD were noted. Water cystometry and uroflowmetry were done pre- and postoperatively. The International Index of Erectile Function questionnaire and Female Sexual Function Index were used to assess SD among the men and women, respectively.

Results

A total of 43 patients with up to 2.94-year follow-up were included. Urodynamic studies were found to correlate significantly with age, days of bladder involvement, perianal numbness, and motor weakness (p<0.01). In step-wise regression analysis, perianal sensation and overall motor weakness were bladder function determinants. Bladder function recovery was directly related to the number of delay days (t=2.30, p<0.05) and with unilateral leg pain (t=2.15, p<0.05). Significant correlation between SD with age and days of bladder involvement before surgery was found (p<0.01).

Conclusions

Surgery timing is related to patient’s functional and sexual outcomes. Patients with unilateral leg pain and hypocontractile bladder have better outcomes. SD is a remarkable problem in CES.

SHADES of grey - The challenge of 'grumbling' cauda equina symptoms in older adults with lumbar spinal stenosis

Diagnosing cauda equina syndrome is challenging in older adults with lumbar spinal stenosis. Understanding these challenges is vital for clinicians who are faced with difficult decisions about when to refer for investigation or surgical management. This is a growing clinical issue because of the escalating prevalence of lumbar spinal stenosis in our ageing population, and increasing demands on healthcare services including imaging and surgical services. This professional issue explores the challenges and evidence gaps relating to cauda equina syndrome in older adults with lumbar spinal stenosis. The degenerative patho-anatomical changes in the lumbar spine that are responsible for lumbar spinal stenosis also have the potential to lead to a gradual compromise of the cauda equina nerve roots. The clinical presentation may be unclear. As a result, there is a risk that slow-onset 'grumbling' cauda equina symptoms may be overlooked or dismissed in older patients with lumbar spinal stenosis. Furthermore, a lack of standardised diagnostic criteria and management pathways add to the challenges for clinicians diagnosing and managing potential cauda equina compromise associated with lumbar spinal stenosis. We recommend careful assessment, appropriate safety netting, and ongoing clinical monitoring and vigilance when assessing and managing this potentially vulnerable patient group.

Urgent operation improves weakness in cauda equina syndrome due to lumbar disc herniation

Objectives

This study aims to examine the effect of surgical timing on the sphincter function and improvement of motor function in patients with cauda equine syndrome (CES) due to lumbar disc herniation (LDH).

Patients and methods

Between January 2005 and December 2013, a total of 33 patients (18 males, 15 females; mean age 48.6±2.2 years, range, 24 to 73 years) who underwent lumbar spinal surgery and were diagnosed with CES due to LDH were retrospectively analyzed. Data including demographics, muscle weakness, sensory deficit, sphincter control, LDH level, time from the initiation of symptoms to admission, and time to surgery were documented. The latest muscle weakness, sensory deficits, and sphincter control were also recorded. The patients were divided into two groups according to the rate of muscle strength improvement and data including age, sex, and operation time were compared.

Results

The weakness remained unchanged in 11 (33.3%), improved in 13 (39.4%), and returned to normal in nine (27.3%) patients. Sphincter control resolved in five patients. Sensory loss resolved in two patients. While admission duration was shorter in the group with improved muscle strength (p=0.02), there was no significant difference in the time to surgery (p=0.63). Logistic regression analyses revealed that only the admission within 0 to 24 hours was significant for the muscle strength improvement (regression coeeficient [B]=2.83, standard error [SE]=0.86, p=0.006).

Conclusion

A significant improvement in the motor strength can be achieved in patients with CES who are operated within 24 hours. On the other hand, patients with CES should be received surgery immediately when first seen, regardless of the time, since the muscle strength is slightly improved.

Time Factor and Disc Herniation Size: Are They Really Predictive for Outcome of Urinary Dysfunction in Patients With Cauda Equina Syndrome?

BACKGROUND

Timing of surgery and the importance of the size of disc prolapse in cauda equina syndrome (CES) remain controversial.

OBJECTIVE

To investigate whether there is a relationship between postoperative urinary function, preoperative duration of neurogenic lower urinary tract dysfunction (NLUTD), and the level of canal compromise.

METHODS

Seventy-one patients operated for CES were prospectively identified between 2010 and 2013. Fifty-two cases with preoperative NLUTD were included. The "Prolapse: Canal ratio" (PCR) was calculated as a proportion of cross-sectional area of disc prolapse on total cross-sectional area of spinal canal.

RESULTS

Median of preoperative duration of NLUTD was 72 h (48; 132) and period from first assessment to surgery 10.5 h (7; 18.5). Urinary incontinence was seen in 46.2% of patients, 38.4% had painless retention and 15.4% had painful retention. In 38.5% of cases, urinary symptoms persisted for more than 20 mo postoperatively. There was no correlation between duration of preoperative NLUTD and urinary dysfunction persistence (P = .921). The outcome was not significantly influenced by having surgery more than the 48 h after presentation (P = .135). Preoperative incontinence persisted in 58% and painless retention in 30% of cases. The mean PCR was 0.6 ± 0.18. There was no correlation between PCR and outcome (P = .537) even after adjusting for duration of preoperative NLUTD (P = .7264).

CONCLUSION

No significant correlation was demonstrated between the preoperative duration of urinary dysfunction, the size of disc herniation relative to size of spinal canal, and postoperative urinary function in a large consecutive series of patients with CES.

An assessment of patient-reported long-term outcomes following surgery for cauda equina syndrome

Background

Data regarding long-term outcomes following surgery for cauda equina syndrome (CES) is scarce. In addition, these studies rely on patient descriptions of the presence or absence of symptoms, with no gradation of severity. This study aimed to assess long-term bladder, bowel, sexual and physical function using validated questionnaires in a CES cohort.

Methods

A pre-existing ethically approved database was used to identify patients who had undergone surgery for CES between August 2013 and November 2014. Patients were contacted over a 1-month period between August and September 2017 and completed validated questionnaires via telephone, assessing bladder (Urinary Symptom Profile), bowel (Neurogenic Bowel Dysfunction Score), sexual dysfunction (Arizona Sexual Experiences Scale) and physical function (Physical Component Summary of SF-12 Questionnaire), with scores compared between those presenting with incomplete CES (CES-I) and CES with retention (CES-R). Patients were also asked which of their symptoms currently they would most value treatment for and what healthcare services they had accessed post-operatively.

Results

Forty-six of 77 patients (response rate 72%, inclusion rate 60%) with a mean age of 45 years (21–83) and mean time since admission of 43 months (range 36–60) took part in the follow-up study. The prevalence of bladder dysfunction was 76%, bowel dysfunction 13%, sexual dysfunction 39% and physical dysfunction 48%. Patients presenting with CES-R had significantly worse long-term outcomes in bladder (stream domain), bowel and sexual function in compared to those with CES-I. Pain was chosen as the symptom patients would most value treatment for by 57%, but only 7% reported post-operative pain management referral.

Conclusions

With a mean follow-up time of 43 months, these findings confirm the high prevalence of long-term bladder, sexual and physical dysfunction in CES patients and that a diagnosis of CES-R confers poorer outcomes. This study provides useful, objective data to guide the expectations of patients and clinicians.

Evaluation and management of cauda equina syndrome in the emergency department

BACKGROUND

Cauda equina syndrome (CES) may be a devastating disease with the potential for significant patient morbidity. It is essential for emergency clinicians to be aware of how to effectively diagnose and manage this condition.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of CES for the emergency clinician.

DISCUSSION

Cauda equina syndrome is a rare but emergent condition associated with back pain. It can result in severe morbidity and can be due to a variety of causes, most commonly vertebral disc protrusion. Diagnosis is often delayed, which may result in a poor prognosis. Red flags and findings consistent with CES include bilateral neurogenic sciatica, reduced perineal sensation, altered bladder function leading to painless urinary retention, loss of anal tone, and loss of sexual function. In isolation, history and examination findings demonstrate poor sensitivity. Symptoms may occur either suddenly or gradually, and most patients do not present with all of these symptoms. Postvoid bladder volume assessments can assist in the evaluation, but the diagnosis typically involves magnetic resonance imaging (MRI) or computed tomography myelography if MRI is not available. Treatment relies upon surgical consultation and operative intervention for decompression.

CONCLUSION

Cauda equina syndrome can be a difficult diagnosis. However, knowledge of the history and examination findings, imaging, and treatment can assist the emergency clinician in optimizing management of this condition.

Compressive Pressure Versus Time in Cauda Equina Syndrome: A Systematic Review and Meta-Analysis of Experimental Studies

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To examine the relationship between compressive pressure and its duration in cauda equina compression, and the effects of subsequent decompression, on neurophysiological function, and pathophysiology in animal studies. We further aim to investigate these relationships with systemic blood pressure to assess whether a vascular component in the underlying mechanism may contribute to the clinical heterogeneity of this disease.

SUMMARY OF BACKGROUND DATA

The complex relationship between preoperative factors and outcomes in cauda equina syndrome (CES) suggests heterogeneity within CES which may inform better understanding of pathophysiological process, their effect on neurological function, and prognosis.

METHODS

Systematic review identified 17 relevant studies including 422 animals and reporting electrophysiological measures (EP), histopathology, and blood flow. Modeling using meta-regression analyzed the relationship between compressive pressure, duration of compression, and electrophysiological function in both compression and decompression studies.

RESULTS

Modeling suggested that electrophysiological dysfunction in acute cauda equina compression has a sigmoidal response, with particularly deterioration when mean arterial blood pressure is exceeded and, additionally, sustained for approximately 1 hour. Accounting for pressure and duration may help risk-stratify patients pre-decompression. Outcomes after decompression appeared to be related more to the degree of compression, where exceeding systolic blood pressure tended to result in an irreversible lesion, rather than duration of compression. Prognosis was most strongly associated with residual pre-decompression function.

CONCLUSION

Compressive pressure influences effects and outcomes of cauda equina compression. We suggest the presence of two broad phenotypic groups within CES defined by the degree of ischaemia as a potential explanatory pathophysiological mechanism.

LEVEL OF EVIDENCE

1.

Are we neglecting sexual function assessment in suspected cauda equina syndrome?

OBJECTIVES

We assessed the documentation rates of signs and symptoms, including sexual function, in patients with suspected cauda equina syndrome and whether they can be improved by increasing local awareness.

PATIENTS AND METHODS

We reviewed all electronic records of patients referred with suspected CES who required urgent MRI to our regional service over a 2 month period. We recorded the documentation rates of clinical signs and symptoms. The results were presented locally to increase awareness. A further 2 month period was then re-audited. 120 patients in total were included across both time periods. Chi-squared was used to compare documentation rates between time periods.

RESULTS

25 of 120 patients had radiological cauda equina compression. Lower limb neurology, urinary function and saddle sensation were almost universally documented. After the intervention, there was a significant increase (p < 0.05) in the documentation of bowel function and post-void residual but not sexual function. Sexual function was poorly documented with rates of 3% and 11% throughout the two audited periods.

CONCLUSION

Certain clinical features of CES are well documented. Increasing awareness may improve documentation of certain symptoms/signs in patients with suspected cauda equina syndrome. Sexual function was poorly documented and increasing awareness alone is an inadequate intervention.

Spinal Emergencies in Primary Care Practice

Atraumatic spinal emergencies often present a diagnostic and management dilemma for health care practitioners. Spinal epidural abscess, cauda equina syndrome, and spinal epidural hematoma are conditions that can insidiously present to outpatient medical offices, urgent care centers, and emergency departments. Unless a high level of clinical suspicion is maintained, these clinical entities may be initially misdiagnosed and mismanaged. Permanent neurologic sequela and even death can result if delays in appropriate treatment occur. A focused, critical review of 34 peer-reviewed articles was performed to identify current data about accurate diagnosis of spinal emergencies. This review highlights the key features of these 3 pathological entities with an emphasis on appropriate diagnostic strategy to intervene efficiently and minimize morbidity.

Outcomes Reported After Surgery for Cauda Equina Syndrome: A Systematic Literature Review

STUDY DESIGN

This is a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

OBJECTIVE

To assess the outcomes reported in trials and observational studies of surgery for cauda equina syndrome (CES), and to inform the development of a core outcome set.

SUMMARY OF BACKGROUND DATA

Scoping searches revealed that there were inconsistencies in which outcomes were reported and how they were measured in research studies for patients who had undergone surgery for CES.

METHODS

Ovid Medline, Embase, CINAHL Plus, and trial registries were searched from January 1, 1990 to September 30, 2016 with the term "cauda equina syndrome." Inclusion and exclusion criteria were applied according to study design, diagnosis, procedure, publication date, language, and patient age. Data extracted included demographics, study design, the outcomes reported, and their definition. We also assessed variation in the use of terminology for each outcome domain.

RESULTS

A total of 1873 articles were identified, of which 61 met the inclusion criteria. Of these, 737 outcomes reported verbatim were categorized into 20 core outcome domains and 12 subdomains with a range of 1 to 141 outcomes per outcome domain or subdomain. The most commonly reported outcomes were bladder function (70.5%), motor function (63.9%), and sensation (50.8%). Significant variation in the terms used for each outcome was documented, for example, bladder function outcome domain had 141 different terms.

CONCLUSION

There is significant heterogeneity in outcomes reported for studies after surgery for CES patients. This indicates a clear need for the development of a core outcome set, which has been registered as number 824 on the COMET (Core Outcome Measure in Effectiveness Trials) database.

LEVEL OF EVIDENCE

1.

Sexual activity after spine surgery: a systematic review

INTRODUCTION

Sexual function is an important determinant of quality of life, and factors such as surgical approach, performance of fusion, neurological function and residual pain can affect it after spine surgery. Our aim was to perform a systematic review to collate evidence regarding the impact of spine surgery on sexual function.

METHODS

A systematic review of studies reporting measures of sexual function, and incidence of adverse sexual outcomes (retrograde ejaculation) after major spine surgery was done, regardless of spinal location. Pubmed (MEDLINE) and Google Scholar databases were queried using the following search words "Sex", "Sex life", "Sexual function", "Sexual activity", "retrograde ejaculation", "Spine", "Spine surgery", "Lumbar surgery", "Lumbar fusion", "cervical spine", "cervical fusion", "Spinal deformity", "scoliosis" and "Decompression". All articles published between 1997 and 2017 were retrieved from the database. A total of 81 studies were included in the final review.

RESULTS

Majority of the studies were retrospective case series and were low quality (Level IV) in evidence. Anterior lumbar approaches were associated with a higher incidence of retrograde ejaculation, especially with the utilization of transperitoneal laparoscopic approach. There is inconclusive evidence on the preferred sexual position following fusion, and also on the impact of BMP-2 usage on retrograde ejaculation/sexual dysfunction.

CONCLUSION

Despite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery. Future studies incorporating specific assessments of sexual activity will be required to address this important determinant of quality of life so that appropriate pre-operative counselling can be done by providers. These slides can be retrieved under Electronic Supplementary Material.

Influence of timing of surgery on Cauda equina syndrome: Outcomes at a national spinal centre

PURPOSE

There is no doubt that the best outcome achieved in Cauda equina syndrome (CES) involves surgical decompression. The controversy regarding outcome lies with timing of surgery. This study reports outcomes on a large population based series. Timing of surgery, Cauda Equina syndrome classification based on British Association of Spine Surgeons (BASS) guidelines and co-morbid illness will be assessed to evaluate influence on outcome.

MATERIALS AND METHODS

A retrospective review of all patients surgically decompressed for CES between 01/01/2008 to 01/08/2014 was conducted. Patients with ongoing symptoms were followed up for a minimum of 2 years. Cauda Equina Syndrome (CES) was classified according to the BASS criteria: CES suspicious (CESS), incomplete (CESI) and painless urinary retention (CESR). Time and symptom resolution were assessed.

RESULTS

A total of 136 patients were treated for CES; 69 CESR, 22 CESI and 45 CESS. There was no statistical difference in age, sex, smoking status and alcohol status with regards to timing of surgery. No correlation between increasing co-morbidity score and poor outcome was demonstrated in any subgroupAll CESR/I patients demonstrated some improvement in bowel and bladder dysfunction post-operatively. No significant difference in improved autonomic dysfunction was demonstrated in relation to timing of surgery. CES subclassification may predict outcome of non-autonomic symptoms. Statistically better outcomes were found in CESS groups with regards to post-operative lower back pain (P 0.049) and saddle paraesthesia (P 0.02).

CONCLUSION

Surgical Decompression for CES is an effective treatment that significantly improves patient symptoms including bowel and bladder dysfunction Early surgical decompression <24 h from symptom onset does not appear to significantly improve resolution of bowel or bladder dysfunction.

Incomplete Cauda Equina Syndrome Presenting with Acute Urinary Retention in the Emergency Department

Cauda equina syndrome (CES) is a rare but serious neurosurgical emergency that can have devastating long-lasting neurologic consequences. CES caused by herniated lumbar discs is rare in the literature. We report an unusual case of incomplete CES due to lumbar disc herniation. The patient presented to our emergency department with acute onset of low back pain, saddle (perineal) anaesthesia, urinary retention and constipation without motor deficit or sciatica. Magnetic resonance imaging (MRI) revealed a large herniated disc originated from the L5-S1 disc space with compression of the cauda equina. This case illustrates that patients with CES accompanying a disc herniation may not have all the characteristic features of CES such as pain radiating to the legs or muscle weakness. We recommend that urgent MRI assessment should be performed in all patients who present with sudden onset of urinary symptoms in the context of lumbar back pain or loss of perineal sensation.

Epidemiology of cauda equina syndrome. What changed until 2015

Objective

The primary objective of this study was to analyze the characteristics and outcomes of cases admitted to hospital with cauda equina syndrome (CES) at the Institute of Orthopedics and Traumatology (IOT) from 2005 to 2015. Secondly, this article is a continuation of the epidemiological work of the same base published in 2013, and will be important for other comparative studies to a greater understanding of the disease and its epidemiology.

Methods

This was a retrospective study of the medical records of admissions due to CES at IOT in the period 2005–2015 with diagnosis of CES and neuropathic bladder. The following variables were analyzed: gender, age, etiology of the disease, topographic level of the injury, time interval between injury and diagnosis, presence of neurogenic bladder, time interval between diagnosis of the CES and surgery, and reversal of the deficit or of the neurogenic bladder.

Results

Since this is a rare disease, with a low global incidence, it was not possible, just with the current study to establish statistically significant correlations between the variables and outcomes of the disease. However, this study demonstrates the shortcomings of the Brazilian public health system, both with the initial management of these patients and the need for urgent surgical treatment.

Conclusion

The study shows that despite well-defined basis for the conduct of CES, a higher number of sequelae caused by the pathology is observed in Brazil. The delay in diagnosis and, therefore, for definitive treatment, remains as the major cause for the high number of sequelae. Level of evidence: 4, case series.

Analysis of clinical and neurological outcomes in patients with cauda equina syndrome caused by acute lumbar disc herniation: a retrospective-prospective study

OBJECTIVES

In this research we analyzed the results of surgical treatment of cauda equina syndrome (CES) caused by acute lumbar disc herniation. We emphasize the early treatment for good neurological recovery.

METHODS

A retrospective-prospective, non randomized, clinical study was performed between Jan 2010 and Dec 2014. We retrospectively collected medical records of 18 patients who suffered from CES due to acute lumbar disc herniation and followed up them regularly. Visual analogue scale (VAS) score, lumbar JOA score (29 points), RR (recovery rate) and Oswestry disability index (ODI) questionnaire were used to evaluate clinical outcomes.

RESULTS

All patients were followed up for at least two years. Lumbar disc herniation is located at L2-3 level in 2 cases, L3-4 level in 2 cases, L4-5 level in 9 cases, L5-S1 level in 5 cases. VAS score is 6±2.5 preoperatively and 1.5±1.0 postoperatively at last follow-up (P<0.001). JOA score is 5±3.5 preoperatively, while it is 20±7 postoperatively at last follow-up (P<0.001). RR ≥ 50% was found in 12 cases. ODI is 75%±25% preoperatively, while it becomes 28%±16% postoperatively at last follow-up (P<0.001). It also shows that advanced age (≥45 years) may act as a risk factor for poor RR(<50%), while early operation (duration before surgery, <48 h) proves to be a protective factor.

CONCLUSIONS

Early operations are mandatory and closely relevant to final outcomes for CES patients. However, elder patients are more likely to have poor clinical effect after surgery.

Impact of bladder, bowel and sexual dysfunction on health status of people with thoracolumbar spinal cord injuries living in the community

OBJECTIVE

The disruption of autonomic function following a spinal cord injury (SCI) is common and can negatively affect quality of life. The objective of this study was to describe the prevalence of bladder/bowel incontinence and sexual dysfunction in community-dwelling individuals with a thoracolumbar SCI and examine the impact on general physical and mental health status.

METHODS

Participants who sustained a traumatic SCI to the thoracolumbar region of the spinal cord and classified as American Spinal Injury Association Impairment Scale (AIS) A to D were recruited. Demographic, injury data, MRI classification and neurological data were collected on admission. At follow-up, the neurological data, a questionnaire collecting participant-reported secondary health conditions (SHCs) (e.g. bladder incontinence, depression etc.) following SCI and health status measured by Short Form-36 were obtained. Regression models determined the association of health status with demographic/injury-related data, types and number of SHCs.

RESULTS

Of the 51 participants, 58.8% reported bladder incontinence, 54.0% bowel incontinence, 60.8% sexual dysfunction and 29.4% had all three. The regression models demonstrated that age at injury, bowel incontinence, sexual dysfunction, presence of pain, motor score at follow-up and the number of SHCs were significant predictors of health status. The number of SHCs was more predictive than all other demographic and injury variables for health status.

CONCLUSION

Results highlight the high prevalence of self-reported bowel/bladder incontinence and sexual dysfunction in the traumatic thoracolumbar SCI population and support the need for standardized assessments. Several demographic, injury-related and SHCs impacted health status and should be considered for the management of individuals living in the community.

Cauda Equina Syndrome in a Lactating Mother - A Safe Treatment Approach

Cauda equina syndrome is widely considered as a surgical emergency. The cause of cauda equina syndrome usually is a large central lumbar disc herniation, prolapse or sequestration. Decompression at the earliest has been suggested by many authors but the planning of surgical management becomes challenging when the patient is a breastfeeding mother. Fear of harmful effects of the drugs (administered in the mother) on the infant, always confuses clinicians regarding the treatment approach. So the multidisciplinary approach is necessary with involvement of anaesthetist, paediatrician and also a gynaecologist if necessary. Thorough knowledge of the safety of drugs to be used in operative and post operative period becomes a necessity keeping the baby into consideration. We present a case of one month postpartum female with cauda equina syndrome and present a stepwise multidisciplinary approach, which involves active contributions from surgeon, for safety of the mother and the infant.

Spinal Cord Injury Clinical Registries: Improving Care across the SCI Care Continuum by Identifying Knowledge Gaps

Timely access and ongoing delivery of care and therapeutic interventions is needed to maximize recovery and function after traumatic spinal cord injury (tSCI). To ensure these decisions are evidence-based, access to consistent, reliable, and valid sources of clinical data is required. The Access to Care and Timing Model used data from the Rick Hansen SCI Registry (RHSCIR) to generate a simulation of healthcare delivery for persons after tSCI and to test scenarios aimed at improving outcomes and reducing the economic burden of SCI. Through model development, we identified knowledge gaps and challenges in the literature and current health outcomes data collection throughout the continuum of SCI care. The objectives of this article were to describe these gaps and to provide recommendations for bridging them. Accurate information on injury severity after tSCI was hindered by difficulties in conducting neurological assessments and classifications of SCI (e.g., timing), variations in reporting, and the lack of a validated SCI-specific measure of associated injuries. There was also limited availability of reliable data on patient factors such as multi-morbidity and patient-reported measures. Knowledge gaps related to structures (e.g., protocols) and processes (e.g., costs) at each phase of care have prevented comprehensive evaluation of system performance. Addressing these knowledge gaps will enhance comparative and cost-effectiveness evaluations to inform decision-making and standards of care. Recommendations to do so were: standardize data element collection and facilitate database linkages, validate and adopt more outcome measures for SCI, and increase opportunities for collaborations with stakeholders from diverse backgrounds.

The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome

BACKGROUND

Cauda equina syndrome (CES) is a rare neurologic complication of lumbar herniated disc for which emergency surgical decompression should be undertaken. Despite the common belief that the restoration of functions that are affected by CES can take several years postoperatively, follow up seldom exceeds the first year after surgery. Long term outcome of especially micturition, defecation and sexual function-which are by definition affected in CES-are unknown. The aim of this study is to evaluate 1) postoperative long term outcome of micturition, defecation and sexual function in CES patients 2) attitude of patients towards received hospital care with regard to (recovery of) these functions.

METHODS

CES patients were selected by screening the records of all patients operated on lumbar herniated disc in our university hospital between 1995-2010. A questionnaire was sent to the selected CES patients evaluating current complaints of micturition, defecation and sexual function and attitude towards delivered care with focus on micturition, defecation and sexual function.

RESULTS

Thirty-seven of 66 eligible CES patients were included (response rate 71%, inclusion rate 56%). Median time after surgery was 13.8 years (range 5.8-21.8 years). Dysfunction at follow up was highly prevalent: 38% micturition dysfunction, 43% defecation dysfunction and 54% sexual dysfunction. Younger age at presentation was associated with sexual dysfunction at follow up: for every year younger at presentation, odds ratio for sexual dysfunction at follow up was 1.11 (p = 0.035). Other associations with outcome were not identified. Two-third of the CES patients wished their neurosurgeon had given them more prognostic information about micturition, defecation and sexual function.

CONCLUSION

The presented data demonstrate that dysfunction of micturition, defecation and sexual function are still highly prevalent in a large number of CES patients even years postoperatively. These alarming follow up data probably have a devastating effect on personal perceived quality of life, which should be studied in more detail. CES patients communicate a clear demand for more prognostic information. The presented figures enable clinicians to inform their CES patients more realistically about long term postoperative outcome of micturition, defecation and sexual function after surgical intervention.

Cauda Equina Syndrome: presentation, outcome, and predictors with focus on micturition, defecation, and sexual dysfunction

BACKGROUND

Even though micturition, defecation, and sexual function are substantially affected in cauda equina syndrome (CES), data on outcome are scarce.

METHODS

Medical files of patients operated on lumbar herniated disc were screened for CES and retrospectively analyzed for baseline characteristics, outcome of micturition, defecation, and sexual function and possible predictors.

RESULTS

Seventy-five CES patients (52% men) were included with a mean age of 44 years. L5-S1 was the most common affected level. Duration of CES complaints at presentation was, on average, 84 h (median 48 h). Prevalence of symptoms at presentation: sciatica (97%), altered sensation of the saddle area (93%), micturition dysfunction (92%), and defecation dysfunction (74%). Only 26 patients were asked about sexual dysfunction of whom 25 patients experienced dysfunction. Female gender was associated with more defecation dysfunction at presentation than male gender (OR 4.11; p = 0.039). All patients underwent decompressive surgery. Two post-operative follow-up (FU) moments took place after a mean of 75 h and 63 days. Outcomes at second FU moment: micturition dysfunction 48%, defecation dysfunction 42%, sexual dysfunction 53%, sciatica 48%, and altered sensation of the saddle area 57%. A shorter time to decompression was associated with more sciatica at FU 1 (p = 0.042) which effect had disappeared at FU 2.

CONCLUSION

This study is unique in (1) displaying the presenting features in a large cohort of CES patients, (2) demonstrating that recovery after decompression is slow and far from complete in the majority of patients with regard to micturition, defecation, and sexual function and (3) evaluating predictors for outcome.

Altered Colorectal Compliance and Anorectal Physiology in Upper and Lower Motor Neurone Spinal Injury May Explain Bowel Symptom Pattern

OBJECTIVES

Supraconal spinal cord injury (SCI) and lower motor neurone spinal cord injury (LMN-SCI) cause bowel dysfunction; colorectal compliance may further define its pathophysiology. The aim of this study was to investigate rectal (RC) and sigmoid (SC) compliance and anorectal physiology parameters, in these subjects.

METHODS

Twenty-four SCI subjects with gut symptoms (14 RC, 10 SC) and 13 LMN-SCI subjects (9 RC, 4 SC) were compared with 20 spinal intact controls (10 RC, 10 SC). Staircase distensions were performed using a barostat. Anorectal manometry, including rectoanal inhibitory reflex (RAIR) measurement, was performed in all. Data presented as mean±standard error (SCI/LMN-SCI vs. controls).

RESULTS

SCI subjects had a higher RC (17.0±1.9 vs. 10.7±0.5 ml/mm Hg, P<0.05) and SC (8.5±0.6 vs. 5.2±0.5 ml/mm Hg, P=0.002). LMN-SCI subjects had a lower RC (7.3±0.7 ml/mm Hg, P=0.0021) while SC was unchanged (8.3±2.2 ml/mm Hg, P>0.05). Anal resting pressure was decreased in SCI (55±5 vs. 79±7 cmH2O, P=0.0102). Anal squeeze pressure was decreased in LMN-SCI (76±13 vs. 154±21 cmH2O, P=0.0158). In SCI and LMN-SCI, the amplitude reduction of the RAIR was greater (62±4% and 70±6% vs. 44±3%, P=0.0007).

CONCLUSIONS

Colorectal compliance abnormalities may explain gut symptoms: increased RC and SC contributing to constipation in SCI, reduced rectal compliance contributing to fecal incontinence (FI) in LMN-SCI. Reduced resting anal pressure in SCI and reduced anal squeeze pressure in LMN-SCI along with a greater RAIR amplitude reduction may be factors in FI. These co-existing abnormalities may explain symptom overlap, and represent future therapeutic targets to ameliorate neurogenic bowel dysfunction.

Urgent discectomy: Clinical features and neurological outcome

Background:

To evaluate the clinical features and outcome of patients with progressive neurological deficits due to disc herniation who were treated surgically within 24 h.

Methods:

We conducted a retrospective analysis of consecutive patients who were admitted between 2004 and 2013 via the Emergency Department. Records were screened for presenting symptoms, neurological status at admission, discharge, and 6-week follow-up.

Results:

About 72 of 526 patients underwent surgery within 24 h. Magnetic resonance imaging showed lumbar disc herniation in 72 patients. The most common presenting symptoms included radiculopathy (n = 69), the Lasègue sign (n = 60), sensory deficits (n = 57), or motor deficits (n = 47). In addition, 11 patients experienced perineal numbness and 12 had bowel and bladder dysfunction. At discharge, motor and sensory deficits and bowel and bladder dysfunction had improved significantly (P < 0.001, P = 0.029, and P = 0.015, respectively).

Conclusion:

Motor deficits, sensory deficits, and cauda equina dysfunction were significantly improved immediately after urgent surgery. After 6 weeks, motor and sensory deficits were also significantly improved compared to the neurological status at discharge. Thus, we advocate immediate surgery of disc herniation in patients with acute onset of motor deficits, perineal numbness, or bladder or bowel dysfunction indicative of cauda equina syndrome.

Cauda equina syndrome secondary to lumbar disc herniation: Surgical delay and its relationship with prognosis

OBJECTIVE

To determine whether surgical treatment delayed for more than 48 hours in patients with cauda equina syndrome (CES) influenced the clinical outcome.

MATERIAL AND METHODS

A retrospective study of 18 patients treated in our hospital from March 2000 to January 2012, after presenting with CES. The pre- and post-operative clinical status was determined: existence of back pain and/or sciatica, sensory disturbance in the perineum, sensory and motor deficits in the lower extremities, and the degree of sphincter incontinence (complete or incomplete CES). A clinical assessment was performed using the Oswestry disability index.

RESULTS

As regards the onset of symptoms, 44% (8 of 18) of patients were treated at an early stage (within 48 hours). None of the patients with complete CES operated in the early stage had urinary incontinence, and also had greater motor recovery. Of the 5 patients with complete CES who underwent delayed surgery, 3 showed residual urinary incontinence. A mean of 12.55 was obtained on the Oswestry disability index scale at the end of follow-up.

CONCLUSION

Although no statistically significant difference was found in our study, we observed greater motor and sphincter recovery in patients who were operated on within 48 hours.