Efficacy of delayed decompression of lumbar disk herniation causing cauda equina syndrome

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.

Factors affecting urinary outcome after delayed decompression in complete cauda equina syndrome: "A regression model study"

PURPOSE

To evaluate the recovery of urinary functions and the factors predicting urinary recovery, following delayed decompression in complete cauda equina syndrome (CESR) secondary to Lumbar disc herniation (LDH).

METHODS

Retrospective study evaluated 19 cases of CESR due to single-level LDH, all presenting beyond 72 h. Mean delay in decompression was 11.16 ± 7.59 days and follow-up of 31.71 ± 13.90 months. Urinary outcomes were analysed on two scales, a 4-tier ordinal and a dichotomous scale. Logistic regression analysis was used for various predictors including delay in decompression, age, sex, radiation, level of LDH, motor deficits, type and severity of presentation. Time taken to full recovery was correlated with a delay in decompression. using Spearman-correlation.

RESULTS

Optimal recovery was seen in 73.7% patients and time to full recovery was moderately correlated with a delay in decompression (r = 0.580, p = 0.030). For those with optimal bladder recovery, mean recovery time was 7.43 ± 5.33 months. Time to decompression and other evaluated factors were not found contributory to urinary outcomes on either scales. Three (15.8%) patients had excellent, 11 (57.9%) had good, while 3 (15.8%) and 2 (10.5%) had fair and poor outcomes respectively.

CONCLUSIONS

Occurrence of CESR is not a point of no-return and complete recovery of urinary functions occur even after delayed decompression. Longer delay leads to slower recovery but it is not associated with the extent of recovery. Since time to decompression is positively correlated with time to full recovery, early surgery is still advised in the next available optimal operative setting.

LEVEL OF EVIDENCE

IV.

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.

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.

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.

[Delayed decompression for cauda equina syndrome secondary to lumbar disc herniation: long-term follow-up results]

OBJECTIVE

To assess the impact of delayed decompression on long-term neurological and bladder function recovery in patients with cauda equina syndrome (CES) secondary to lumbar disc herniation (LDH).

METHODS

The clinical data of 35 patients receiving delayed decompression surgery for CES secondary to LDH were reviewed. The bladder empty function, bowel control, sexual ability and neurological functions of the lower limbs were evaluated after the operation, and the urodynamic changes were assessed in 6 patients with urodynamic data before and after the operation.

RESULTS

Surgical decompression was performed at 4.1±3.9 weeks in 12 patients with complete CES and at 5.5±7.6 weeks in 23 patients with incomplete CES after the onset of symptoms. The patients were followed up for a mean of 43.0±28.9 months (3-110 months). In the 23 patients with incomplete CES, 19 obtained full recovery, 4 had slight sensory alterations in the saddle area or the lower limbs. In the 12 patients with complete CES, 2 had full recovery, 4 reported slight sensory alterations in the saddle area or the lower limbs (including 2 with occasional constipation); 6 still had sense deficit in the saddle area and difficulties in bladder or bowl emptying, but they all reported significant improvements compared to the condition before operation. Urodynamic analysis in the 6 patients with pre-and postoperative urodynamic data showed increased abdominal pressure when voiding with significantly reduced residual urine in all the 6 patients; 4 patients with abnormal first desire volume before operation reported recovery after the operation.

CONCLUSION

Patients with LDH-induced CES who missed the chance of early decompression can still expect favorable functional recovery in the long term. The improvement of bladder function following decompression is probably a result of recovery of bladder sensation and the compensation by increased intra-abdominal pressure. The key strategy to promote bladder function recovery in these patients is to promote the detrusor recovery.

Cauda equina syndrome

There is no universally agreed definition of cauda equina syndrome (CES). Clinical signs of CES including direct rectal examination (DRE) do not reliably correlate with cauda equina (CE) compression on MRI. Clinical assessment only becomes reliable if there are symptoms/signs of late, often irreversible, CES. The only reliable way of including or excluding CES is to perform MRI on all patients with suspected CES. If the diagnosis is being considered, MRI should ideally be performed locally in the District General Hospitals within one hour of the question being raised irrespective of the hour or the day. Patients with symptoms and signs of CES and MRI confirmed CE compression should be referred to the local spinal service for emergency surgery.

CES can be subdivided by the degree of neurological deficit (bilateral radiculopathy, incomplete CES or CES with retention of urine) and also by time to surgical treatment (12, 24, 48 or 72 hour). There is increasing understanding that damage to the cauda equina nerve roots occurs in a continuous and progressive fashion which implies that there are no safe time or deficit thresholds. Neurological deterioration can occur rapidly and is often associated with longterm poor outcomes. It is not possible to predict which patients with a large central disc prolapse compressing the CE nerve roots are going to deteriorate neurologically nor how rapidly. Consensus guidelines from the Society of British Neurological Surgeons and British Association of Spinal Surgeons recommend decompressive surgery as soon as practically possible which for many patients will be urgent/emergency surgery at any hour of the day or night.

Cite this article: Bone Joint J 2015;97-B:1390–4

Neurological deterioration in cauda equina syndrome is probably progressive and continuous. Implications for clinical management

Fifty-six human and animal studies of cauda equina syndrome (CES) were reviewed. The evidence from human studies was poor (level IV). Evidence from animal studies and limited evidence from human studies suggest that structural and functional neurological losses are a progressive, continuous process. The longer the cauda equina nerve roots are compressed the greater the harm and the poorer the extent of recovery. This should prompt diagnosis and surgery for all CES patients as soon as practicably possible.