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Wang Q, Wen M, Hou G, Zhao S, Yao Z, Tu Z, Huang P, Ye B, Xie F, Luo Z, Hu X. Chronic cauda equina syndrome decompression surgery recovery is very "bad"? Based on patient self-assessment. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:932-940. [PMID: 37947889 DOI: 10.1007/s00586-023-07984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/31/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023]
Abstract
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.
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Affiliation(s)
- Qiushi Wang
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Mengyuan Wen
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Guangdong Hou
- Department of Urology, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Shixian Zhao
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Zhou Yao
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Zhipeng Tu
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Peipei Huang
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Bin Ye
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Fang Xie
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China
| | - Zhuojing Luo
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China.
| | - Xueyu Hu
- Department of Orthopaedic, Xijing Hospital, Air Force Medical University, Xi'an, 710032, China.
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Miller J, West J, Khawar H, Middleton R. Cauda equina syndrome. Br J Hosp Med (Lond) 2023; 84:1-7. [PMID: 38186331 DOI: 10.12968/hmed.2023.0012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Cauda equina syndrome is an uncommon but serious cause of lower back pain resulting from compression of the cauda equina nerve roots, most commonly by lumbar disc herniation. Red flag symptoms, such as bladder dysfunction, saddle anaesthesia and sciatica, should lead to high clinical suspicion of cauda equina syndrome. The British Association of Spinal Surgeons has published an updated standard of care for these patients because of the potentially debilitating effects of missed cases of cauda equina syndrome. This review summarises these standards and provides a framework to support quick triage of at-risk patients. Immediate magnetic resonance imaging, within 1 hour of presentation to the emergency department, is crucial in patients with suspected cauda equina syndrome to allow prompt diagnosis and treatment. Urgent decompressive surgery is usually recommended for the best outcomes, to reduce morbidity and complication rates.
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Arnold J, Koyfman A, Long B. High risk and low prevalence diseases: Acute limb ischemia. Am J Emerg Med 2023; 74:152-158. [PMID: 37844359 DOI: 10.1016/j.ajem.2023.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/26/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization. CONCLUSIONS An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Jacob Arnold
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Filler R, Nayak R, Razzouk J, Ramos O, Cannon D, Brandt Z, Thakkar SC, Parel P, Chiu A, Cheng W, Danisa O. The Reoperation, Readmission, and Complication Rates at 30 Days Following Lumbar Decompression for Cauda Equina Syndrome. Cureus 2023; 15:e49059. [PMID: 38116344 PMCID: PMC10730150 DOI: 10.7759/cureus.49059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023] Open
Abstract
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.
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Affiliation(s)
- Ryan Filler
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Rusheel Nayak
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Jacob Razzouk
- Department of Orthopaedic Surgery, School of Medicine, Loma Linda University, Loma Linda, USA
| | - Omar Ramos
- Spine Surgery, Twin Cities Spine Center, Minneapolis, USA
| | - Damien Cannon
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
| | - Zachary Brandt
- School of Medicine, Loma Linda University, Loma Linda, USA
| | | | - Philip Parel
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington D.C., USA
| | - Anthony Chiu
- Department of Orthopaedics, University of Maryland, Baltimore, USA
| | - Wayne Cheng
- Division of Orthopaedic Surgery, Jerry L. Pettis VA Medical Center, Loma Linda, USA
| | - Olumide Danisa
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, USA
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John A, Simjian T, Lamba N, Yuxin Y, Carosella C, Song J, Trinh S, Lak AM, Mammi M, Zaidi H, Mekary RA. A comparison of the safety and efficacy of minimally invasive surgery versus open surgery in treating cauda equina syndrome: A systematic review and meta-analysis. J Clin Neurosci 2023; 117:98-103. [PMID: 37783070 DOI: 10.1016/j.jocn.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE To compare the safety and efficacy of minimally invasive surgery (MIS) and open surgery (OS) in treating cauda equina syndrome (CES). METHODS A systematic literature search was conducted, searching relevant databases for studies investigating MIS and/or OS in treating CES. Pooled outcomes and their 95% confidence intervals (CIs) were meta-analyzed via random-effects models. RESULTS Ten studies were included in the meta-analysis. Pooled mean operation times were shorter for MIS (75.4 min; 95 %CI: 40.8, 110.0) than OS (155.1 min; 121.3, 188.9). Similarly, mean hospital stay was shorter for MIS (4.08 days; 2.77, 5.39 vs. 8.85 days; 6.56, 11.13). Mean blood loss was smaller for MIS (71.7 mL; 0, 154.5 vs. 366.5; 119.1, 614.0). Mean post-op lumbar/back visual analogue scale (VAS) score was lower for MIS (3.65; 2.75, 4.56 vs. 5.80; 4.55, 7.05). Mean post-op leg VAS score was 1.27 (0.41, 21.4) for MIS and 1.29 (0.47, 2.12) for OS. Mean complete bladder recovery rate was 81.0% (55.0%, 94.0%) for MIS and 75.0% (44.0%, 92.0%) for OS. Mean complete motor recovery rate was larger for MIS (70.0%; 48.0, 85.0 vs. 42.0%; 34.0, 51.0). Mean percentages of "excellent" patient outcomes were equal for MIS (64.0%; 48.0%, 77.0%) and OS (64.0%; 22.0%, 92.0%). CONCLUSION MIS for CES was associated with reduced operative time, length of stay, and blood loss, compared to OS. MIS was also associated with better post-operative lumbar/back and leg VAS scores and complete motor and bladder recovery rates. MIS and OS produced an equal average percentage of "excellent" patient outcomes.
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Affiliation(s)
- Alvin John
- College of Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY, USA; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Simjian
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Nayan Lamba
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yao Yuxin
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Claudia Carosella
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Jimin Song
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Stephanie Trinh
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Asad M Lak
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Marco Mammi
- Neurosurgery Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Hasan Zaidi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA.
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Aprato A, Branca Vergano L, Casiraghi A, Liuzza F, Mezzadri U, Balagna A, Prandoni L, Rohayem M, Sacchi L, Smakaj A, Arduini M, Are A, Battiato C, Berlusconi M, Bove F, Cattaneo S, Cavanna M, Chiodini F, Commessatti M, Addevico F, Erasmo R, Ferreli A, Galante C, Giorgi PD, Lamponi F, Moghnie A, Oransky M, Panella A, Pascarella R, Santolini F, Schiro GR, Stella M, Zoccola K, Massé A. Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures. J Orthop Traumatol 2023; 24:46. [PMID: 37665518 PMCID: PMC10477162 DOI: 10.1186/s10195-023-00726-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/02/2023] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment. MATERIALS AND METHODS The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment. RESULTS Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated. CONCLUSIONS This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients. LEVEL OF EVIDENCE IV. TRIAL REGISTRATION not applicable (consensus paper).
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Affiliation(s)
- Alessandro Aprato
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy.
| | | | | | | | - Umberto Mezzadri
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | - Alberto Balagna
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
| | | | | | | | | | | | | | | | | | - Federico Bove
- ASST Grande Ospedale Metropolitano Niguarda di Milano, Milan, Italy
| | | | | | | | | | | | - Rocco Erasmo
- Ospedale Civile Santo Spirito di Pescara, Pescara, Italy
| | | | | | | | | | | | - Michel Oransky
- Università degli studi di Roma, ASST degli spedali Civili di Brescia, Brescia, Italy
| | | | | | | | | | | | | | - Alessandro Massé
- Università degli studi di Torino, Viale 25 Aprile 137 Int 6, 10133, Turin, Italy
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Kim HS, Kim JY, Lee YJ, Lee JH, Jang IT. Minimally Neural Retractive, Total Annular Resection, Transforaminal Endoscopic (TARTE) Approach for Severely Canal Compromising Lumbar Disk Herniation Accompanied by a Neurologic Deficit. J Neurol Surg A Cent Eur Neurosurg 2023; 84:334-342. [PMID: 35108743 DOI: 10.1055/s-0041-1741548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Treatment of severely canal compromising lumbar disk herniations (LDH), occupying more than 50% of the canal area, are associated with technical difficulty and worse outcomes. This study aimed to describe new techniques of transforaminal endoscopic lumbar diskectomy (TELD) with less neural retraction, and total annular resection for broad-based severely canal compromising disk herniation. We also evaluated the feasibility and safety of the techniques, and analyzed the clinical and radiologic outcomes of 32 patients presenting with neurologic deficits. METHODS A retrospective cohort study was performed with 32 consecutive patients who underwent TELD for broad-based severely canal compromising LDH between January 2018 and January 2020. We removed the LDH using two novel techniques: (1) the "mobile outside-in" approach and total annular resection method and (2) internal decompression and subsequent pushdown method of the migrated fragment. The cross-sectional area (CSA) on magnetic resonance image was evaluated preoperatively and compared with the postoperative image within 7 days and between 6 months and 1 year. The visual analog scale (VAS) for back and leg pain, Oswestry disability index (ODI), MacNab's criteria, and motor power of the involved lower extremities were evaluated pre- and postoperatively. RESULTS A total of 32 patients, with an average age of 37.5 years (range: 17-66), underwent surgery. The mean VAS score for back pain improved from 7.84 ± 1.02 to 1.31 ± 0.54 and the ODI score improved from 74.3 ± 7.82 to 20.4 ± 3.71 at final follow-up. According to MacNab's criteria, 23 patients had excellent and 9 patients had good outcomes at final follow-up. All patients operated on at the L4-L5 level had great toe/ankle dorsiflexion and/or ankle plantar flexion weakness; knee extension weakness was found at the L2-L3 and L3-L4 levels. Motor function improved significantly; the mean values and range preoperatively, and at 1 month, 3 months, and final follow-up, were 3.41 ± 0.95 (1-4), 4.56 ± 0.56 (3-5), 4.88 ± 0.34 (4-5), and 4.97 ± 0.18 (4-5), respectively (p < 0.001, at all follow-up). The mean values and range of the preserved CSA proportion, preoperatively and within 1 week after surgery, and at final follow-up were 34.9 ± 10.9 (15-61), 81.06 ± 10.24 (63-97), and 93.03 ± 5.37 (76-99), respectively (p < 0.001, at all follow-up). CONCLUSION The transforaminal endoscopic approach for broad-based severely canal compromising LDH can be considered a feasible surgical option for an experienced surgeon. With total annular resection and pushdown of migrated fragments, safe and complete removal of LDH was possible in patients with a neurologic deficit. Total annular resection may increase the overall but not the early recurrence rate.
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Affiliation(s)
- Hyeun Sung Kim
- Department of Neurosurgery, Nanoori Hospital Seoul, Gangnam-gu, Seoul, Republic of Korea
| | - Ji Yeon Kim
- Department of Neurosurgery, Spine Center, Leon Wiltse Memorial Hospital, Anyang, Republic of Korea
| | - Yeon Jin Lee
- Department of Neurosurgery, Nanoori Hospital Seoul, Gangnam-gu, Seoul, Republic of Korea
| | - Jun Hyung Lee
- Department of Internal Medicine, Chosun University Hospital, Gwangju, Republic of Korea
| | - Il-Tae Jang
- Department of Neurosurgery, Gangnam Nanoori Hospital, Gangnam-gu, Seoul, Republic of Korea
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Lim DJ. Atypical intradural extramedullary spinal schwannoma causing cauda equina syndrome: A case report and literature review. Int J Surg Case Rep 2023; 108:108396. [PMID: 37311324 DOI: 10.1016/j.ijscr.2023.108396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023] Open
Abstract
INTRODUCTION Spinal schwannomas are slow-growing benign tumors that are generally asymptomatic. However, we describe an atypical case in which an intradural extramedullary schwannoma presented as an acute cauda equina syndrome. PRESENTATION OF CASE This was a 58-year-old woman with a 2-month history of severe low back pain and worsening neurological deficits and a 2-day period of acute onset of lower extremity numbness and urinary incontinence. Physical and neurological examination revealed significant lower extremity weakness, tenderness on palpation of the spine, positive straight leg test bilaterally, decreased sensation below the L4 dermatome, reduced sphincter tone, saddle anesthesia, decreased deep tendon reflexes, and loss of sphincter control, consistent with compression of the cauda equina. Magnetic resonance imaging revealed a large mass of heterogeneous composition at the level of L3 lumbar, intruding into the cauda equina. Wide decompression was successfully performed, and histopathological examination confirmed the diagnosis. With rehabilitation, there was some recovery of lower extremity motor function. DISCUSSION Spinal schwannomas are rare, accounting for only about 2 % of spinal tumors. Cauda equina syndrome is also rare, with an incidence of 0.08-0.27 % among patients presenting with low back pain. Therefore, it is important for clinicians to have an awareness of the possible association between spinal schwannoma and cauda equina syndrome and to complete a comprehensive assessment of patients with back pain, including magnetic resonance imaging. CONCLUSION Early recognition and treatment of a spinal schwannoma causing neurological symptoms can improve patient outcomes.
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Affiliation(s)
- Dong-Ju Lim
- Department of Orthopaedic Surgery, Seoul Spine Institute, Sanggye Paik Hospital, College of Medicine, Inje University, Republic of Korea.
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Zhang Y, Dai Z, Zhao T, Tian J, Xu J, Zhang J. Publication Trends and Hot Spots in Cauda Equina Syndrome: A Bibliometric Analysis and Visualization of Current Research. World Neurosurg 2023; 173:115-121. [PMID: 36754352 DOI: 10.1016/j.wneu.2023.01.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cauda Equina Syndrome (CES) is a relatively uncommon and complex disorder. Recently, there has been a surge in research on CES. Although the research directions are multifarious, the overall research trends are unclear at present. We aimed to identify the 100 most cited articles on CES and analyze the hot spots trends regarding CES related research by bibliometric analysis. METHODS Articles were obtained by conducting an English language search of the Web of Science Core Collection Databases with the keywords "cauda equina syndrome." The initial 390 articles returned from the search were analyzed by VOSviewer. Next, the top 100 most cited articles were further analyzed by title, authors, journal, year of publication, total citations, country of origin, institution, and keywords. RESULTS A total of 390 publications were identified. The top 100 most cited articles were listed in descending order of total citations (range: 196-11). These articles originated from 24 countries; among these countries, the United Kingdom contributed the most publications (n = 29). The most prolific journal was Spine (n = 27), and the University of Edinburgh was the most productive institution (n = 9). CONCLUSIONS The number of publications on CES increased steadily, with a stable rise in recent years. Some publications have been cited more than 100 times, indicating that these findings are widely accepted by relevant clinicians and contribute significantly to the knowledge of CES. This study represents the first bibliometric analysis and visualization of hot spots analysis and research trends on CES. We believe that this will aid clinical researchers in targeting future areas of research.
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Affiliation(s)
- Yaping Zhang
- General Office of the Administration, Zhejiang Provincial People's Hospital, Hangzhou, China; Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China
| | - Zhanqiu Dai
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China; Department of Orthopaedics, The Second Affiliated Hospital of Bengbu Medical College, Anhui, China; Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingxiao Zhao
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China
| | - Jinlong Tian
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China; Department of Orthopaedics, The Second Affiliated Hospital of Bengbu Medical College, Anhui, China
| | - Jiongnan Xu
- Department of Spine Surgery, Zhejiang Provincial People's Hospital, Hangzhou Medical College People's Hospital, Hangzhou, Zhejiang, China; The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jun Zhang
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China; Department of Orthopedics, Zhejiang Provincial People's Hospital Bijie Hospital, Bijie, Guizhou, China.
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10
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Hawa A, Denasty A, Elmobdy K, Mesfin A. The Most Impactful Articles on Cauda Equina Syndrome. Cureus 2023; 15:e38069. [PMID: 37228568 PMCID: PMC10208163 DOI: 10.7759/cureus.38069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Cauda equina syndrome (CES) is an uncommon condition that can lead to permanent neurological deficits if not diagnosed and addressed promptly. Varying prognoses, including retropulsed fracture fragments, disc herniations, and epidural abscesses, can result in CES. Our objective was to identify the top 50 most impactful articles on CES and analyze the characteristics of these publications. In August of 2021, we used the Web of Science Core Collection bibliographic database to query the phrase "cauda equina syndrome." Articles between 1900 and 2021 were included in the search, and these articles were ranked based on the number of citations. The following variables were recorded: title, first author, journal, year of publication, number of citations, country of origin, the institution of publication, and topic of the paper. A total of 2096 articles matched the search criteria. The top 50 most impactful articles ranged from 43 to 439 in their number of citations. All articles on the list were published in English, with the year of publication ranging from 1938 to 2014. The United States accounted for the greatest number of articles published at 27. The medical journal Spine accounted for the greatest number of publications at nine. And the 2000s was the decade with the most cited articles. It is generally acknowledged that the clinical signals for CES are diverse with no predictive value on patient outcomes. Similar uncertainty exists in the etiology of the condition, though CES induced by spinal anesthesia is a factor of particular interest. Additionally, it is generally recognized that delayed diagnosis of the condition often results in permanent neurological deficits. Identification of the most impactful articles on CES is critical in drawing attention to this significant condition.
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Affiliation(s)
- Aasim Hawa
- Orthopedics, University of Rochester Medical Center, Rochester, USA
| | - Adwin Denasty
- Orthopedics, University of Rochester Medical Center, Rochester, USA
| | - Karim Elmobdy
- Orthopedics, University of Rochester Medical Center, Rochester, USA
| | - Addisu Mesfin
- Orthopedics, University of Rochester Medical Center, Rochester, USA
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Roy SS, Barman A, Viswanath A, Sahoo J. Isolated neurocysticercosis of the spine presenting with low back pain and cauda equina syndrome: a case report. Spinal Cord Ser Cases 2022; 8:70. [PMID: 35882852 PMCID: PMC9325787 DOI: 10.1038/s41394-022-00535-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Cysticercosis, caused by Cysticercus cellulosae, is one of the common parasitic diseases that can affect the central nervous system (neurocysticercosis, NCC). Isolated involvement of cysticercosis of the spine, without the involvement of the brain, has been very rarely reported. CASE PRESENTATION This report presented a case, who was presenting with low back pain with radiation and cauda equina syndrome (CES). On MRI, the patient was found to have a subarachnoid cystic lesion at the level of lumbosacral vertebrae. Under neurosurgery, the patient underwent L5/S1 laminectomy, decompression, and excision of the cyst. On histopathological examination, the patient was diagnosed of having Cysticercosis. Immediately after surgery, the patient had neurological deterioration. However, at the end of 1 year, the patient had significant improvement both neurologically and functionally. DISCUSSION Spinal NCC should be considered in the differential diagnosis for a patient, who presents with a cystic lesion in the spinal subarachnoid space. Surgical exploration and excision of the cysts should be conducted not only to establish the diagnosis but also to decompress the cord and peripheral nerves.
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Rates of Future Lumbar Fusion in Patients with Cauda Equina Syndrome Treated With Decompression. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202211000-00001. [PMID: 36322672 PMCID: PMC9633085 DOI: 10.5435/jaaosglobal-d-22-00153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/17/2022] [Indexed: 11/05/2022]
Abstract
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 < 0.001; 5 years: 3.8%, P < 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 < 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.
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Mahajan UV, Labak KB, Labak CM, Herring EZ, Lineberry K, Miller JP, Smith G. Pudendal tumor mimicking cauda equina syndrome and acute radiculopathy: case report. Spinal Cord Ser Cases 2022; 8:71. [PMID: 35918325 PMCID: PMC9345956 DOI: 10.1038/s41394-022-00537-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts. CLINICAL PRESENTATION A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved. CONCLUSION CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc.
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Garg B, Mehta N. Acute Neurological Deficit Due to Sacral Insufficiency Fracture With Coexistent Severe Lumbar Canal Stenosis: A Case Report. HSS J 2022; 18:307-311. [PMID: 35645643 PMCID: PMC9097004 DOI: 10.1177/15563316211006665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India
Institute of Medical Sciences, New Delhi, India
| | - Nishank Mehta
- Department of Orthopaedics, Jai Prakash
Narayan Apex Trauma Center, New Delhi, India,Nishank Mehta, MS, Department of Orthopaedics, Jai
Prakash Narayan Apex Trauma Center, New Delhi 110029, India.
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Vakos A, Dean K, Reeder C, Louis-Jacques A. Management of cauda equina syndrome during pregnancy and postpartum. BMJ Case Rep 2022; 15:e238793. [PMID: 35487643 PMCID: PMC9058678 DOI: 10.1136/bcr-2020-238793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 01/27/2023] Open
Abstract
Cauda equina syndrome (CES) is a rare condition that occurs from multiple nerve root compression. It is considered a surgical emergency because it can lead to permanent neurological damage. There is limited literature regarding management and prognosis of CES for pregnant patients, leaving providers with many questions when encountering patients with this condition. We describe the case of a patient who developed CES during pregnancy. She presented at 30 weeks gestation and successfully underwent surgical decompression in prone position. She later delivered via elective caesarean at term. This case highlights management considerations for pregnant patients with CES, including positioning during surgery and use of regional anaesthesia.
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Affiliation(s)
- Amanda Vakos
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Kathryn Dean
- University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Callie Reeder
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, USA
| | - Adetola Louis-Jacques
- Department of Obstetrics and Gynecology, University of Florida, Gainesville, Florida, USA
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Abstract
Cauda equina syndrome (CES) involves compression of some or all of the lumbar and sacral peripheral nerve roots. However, there is a lack of consensus in the literature regarding the exact diagnosis criteria in this patient population. Much of the pathophysiology has been studied regarding the onset of this condition; however, the long-term effects are not able to be accurately predicted at this time. Recent literature has associated timing to surgical decompression, severity of symptoms at time of onset, and involvement of bladder dysfunction as prognostic indicators of CES.
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Affiliation(s)
- Landon Bulloch
- Atrium Health Department of Orthopaedic Surgery, 1000 Blythe Boulevard, Charlotte, NC 28203, USA.
| | | | - Leo Spector
- OrthoCarolina Spine Center, 2001 Randolph Road, Charlotte, NC 28207, USA
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Babici D, Johansen PM, Newman SL, O'Connor TE, Miller TD. Microdiscectomy Under Local Anesthesia and Spinal Block in a Pregnant Female. Cureus 2021; 13:e20241. [PMID: 35004056 PMCID: PMC8735709 DOI: 10.7759/cureus.20241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 12/02/2022] Open
Abstract
The surgical plan and the anesthetic approach are vital in determining the proper treatment of lumbar disc herniation in pregnancy. The diagnostic tools available, as well as the anesthetic agents and methods of delivery, vary in pregnant patients due to factors such as radiation exposure and hemodynamics in the patient and fetus. The gestational age also plays an important role in determining treatment options. When possible, surgery should be avoided during the first trimester, especially during the period of organogenesis, as general anesthesia can interfere with this process. However, when focal neurological deficits are present, urgent surgical decompression may be necessary. In such cases, the selection of anesthesia must be guided by maternal indications and the nature of the surgery. Maternal safety and avoidance of fetal hypoxia and subsequent preterm labor are crucial when pregnant patients receive anesthesia. As a result, local anesthesia is often preferred when possible due to the decreased risk of systemic toxicity. Decompression surgery in pregnant females with lumbar disc herniation, using a multidisciplinary approach among the surgeon, obstetrician, and anesthesiologist, is an effective and safe procedure for both the mother and the fetus. We present the case of a pregnant female at four weeks of gestation who presented with lower back pain radiating down her right leg. MRI of the lumbar spine showed large L4-5 disc herniation. She underwent a successful right L4-5 microdiscectomy under local anesthesia and spinal block using bupivacaine and was completely awake throughout the procedure. Postoperatively, she experienced immediate improvement of symptoms.
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Kuris EO, McDonald CL, Palumbo MA, Daniels AH. Evaluation and Management of Cauda Equina Syndrome. Am J Med 2021; 134:1483-1489. [PMID: 34473966 DOI: 10.1016/j.amjmed.2021.07.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Eren O Kuris
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Christopher L McDonald
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Mark A Palumbo
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI.
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Asada T, Koda M, Funayama T, Takahashi H, Noguchi H, Miura K, Mataki K, Yamazaki M. Imaging-Based Diagnosis of Epiconus Syndrome From the Distance of the Lesion to Where the Spinal Cord Terminates Not From the Disc Level: A Case Series. Cureus 2021; 13:e17708. [PMID: 34650882 PMCID: PMC8489802 DOI: 10.7759/cureus.17708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2021] [Indexed: 11/05/2022] Open
Abstract
Objective This study aimed to analyze the neurological symptoms caused by thoracolumbar lesions according to their distance from where the spinal cord terminates for a better description of epiconus syndrome. Methods We retrospectively reviewed cases of patients with neurological symptoms caused by a thoracolumbar lesion in a single institute. Neurological symptoms were analyzed according to the distance from the proximal end of the lesion to where the spinal cord terminates using MRI or CT myelograms. The symptoms were classified into epiconus syndrome, thoracic myelopathy, and conus medullaris syndrome. The distance was described regarding the length of a vertebral body (VB). Results We included 19 patients in this series. The spinal cord terminates were at the lower third of the L1 vertebra most frequently (32%) in the range of T12 to L2 vertebra. The border between thoracic myelopathy and epiconus syndrome was 2VB proximal from where the spinal cord terminates, and that between epiconus syndrome and conus medullaris syndrome was 1VB. Mean disease duration until symptoms changed was 2.4 months in epiconus syndrome, while it was 25 months in thoracic myelopathy, and 10.3 months in conus medullaris syndrome. Conclusion Epiconus syndrome is caused by lesion 1-2VB proximal to where the spinal cord terminates. This study may provide further helpful information for clinical practice in the treatment of epiconus syndrome.
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Affiliation(s)
- Tomoyuki Asada
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Masao Koda
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Toru Funayama
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Hiroshi Noguchi
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Kousei Miura
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Kentaro Mataki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, JPN
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Leitner L, Wanivenhaus F, Bachmann LM, Liechti MD, Aguirre JA, Farshad M, Kessler TM. Bladder management in patients undergoing spine surgery: An assessment of care delivery. NORTH AMERICAN SPINE SOCIETY JOURNAL 2021; 6:100059. [PMID: 35141624 PMCID: PMC8820009 DOI: 10.1016/j.xnsj.2021.100059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Lower urinary tract dysfunction is common in the early postoperative phase after spine surgery. Although it is essential for an optimal patient management to balance benefits and harms, it is not known which patient benefit from a perioperative indwelling catheter. We therefore evaluated urological parameters prior and after spine surgery performing a quality assessment of our current clinical practice in bladder management. METHODS Preoperatively, all patients completed the International Prostate Symptom Score and were interviewed for urological history. Decision for preoperative urethral catheter placement was individually made by the responsible anesthesiologist according to an in-house protocol. Within and between group analyses using univariate and probability matching statistics were performed for patients with intraoperative urethral catheter-free management (n = 54) and those with a preoperatively placed catheter (n = 46). Post void residual (PVR) was measured prior and after surgery or after removal of the urethral catheter, respectively. The outcome measures consisted of postoperative urinary retention (POUR) and postoperative urological complications (PUC), defined as POUR and any catheter-related adverse events. RESULTS Hundred patients undergoing spine surgery were prospectively evaluated. Sixteen of the 54 (30%) patients with urethral catheter-free management developed POUR. Length of surgery and volume of intravenous infusion were associated with POUR (p < 0.05). In the 46 preoperatively catheterized patients, re-catheterization was required in 6 (13%). In a fairly homogenous subgroup of 72 patients with a probability of PUC between 15 and 40%, no significant association between intraoperative urethral catheter-free management and the occurrence of PUC was found (odds ratio 2.09, 95% confidence interval 0.69 to 6.33; p = 0.193). CONCLUSIONS In case of postoperative PVR monitoring allowing de novo catheterization as appropriate, urethral catheter-free management seems to be a valuable option in spine surgery since it does not to increase PUC but minimizes unnecessary catheterizations with their related complications.
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Affiliation(s)
- Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Florian Wanivenhaus
- Spine Division, Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Martina D. Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - José A. Aguirre
- Department of Anesthesia, Intensive Care and Pain Therapy, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Mazda Farshad
- Spine Division, Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Seidel H, Bhattacharjee S, Pirkle S, Shi L, Strelzow J, Lee M, El Dafrawy M. Long-term rates of bladder dysfunction after decompression in patients with cauda equina syndrome. Spine J 2021; 21:803-809. [PMID: 33434651 DOI: 10.1016/j.spinee.2021.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/06/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Henry Seidel
- Pritzker School of Medicine at The University of Chicago, 924 E. 57th St, Suite 104, Chicago, IL 60637, USA
| | - Sarah Bhattacharjee
- Pritzker School of Medicine at The University of Chicago, 924 E. 57th St, Suite 104, Chicago, IL 60637, USA
| | - Sean Pirkle
- Pritzker School of Medicine at The University of Chicago, 924 E. 57th St, Suite 104, Chicago, IL 60637, USA
| | - Lewis Shi
- The University of Chicago, Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Hospitals, Duchossois Center for Advanced Medicine, MC 3079, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL 60637, USA
| | - Jason Strelzow
- The University of Chicago, Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Hospitals, Duchossois Center for Advanced Medicine, MC 3079, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL 60637, USA
| | - Michael Lee
- The University of Chicago, Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Hospitals, Duchossois Center for Advanced Medicine, MC 3079, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL 60637, USA
| | - Mostafa El Dafrawy
- The University of Chicago, Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago Hospitals, Duchossois Center for Advanced Medicine, MC 3079, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL 60637, USA.
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Barbaro K, Midgley J. Priapism, a symptom of claudication of the cauda equina in spinal stenosis. Musculoskelet Sci Pract 2021; 52:102337. [PMID: 33549525 DOI: 10.1016/j.msksp.2021.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 11/30/2022]
Abstract
Priapism is defined as a persistent penile erection in the absence of sexual arousal. This symptom has been documented in patients with spinal stenosis although it is considered a rare finding. The European Association of Urology guidelines on priapism [Salonia et al., 2014] list cauda equina syndrome and spinal stenosis as causative factors for ischemic priapism although the literature describing this phenomenon appears sparse. Priapism can be a rare symptom of lumbar spine stenosis/transient cauda equina compression. This presentation is complex and believed to be a parasympathetic mediated autonomic disorder. This article discusses the relationship between spinal stenosis, cauda equina syndrome and priapism using available literature. Greater awareness of this clinical finding may help clinicians in their clinical decision making. In patients with suspected cauda equina syndrome, subjective enquiry regarding the symptom priapism may add to the patients overall clinical picture.
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Affiliation(s)
- Karl Barbaro
- Musculoskeletal Department, York Teaching Hospital NHS Foundation Trust, York, United Kingdom.
| | - James Midgley
- Musculoskeletal Department, York Teaching Hospital NHS Foundation Trust, York, United Kingdom.
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LoRusso S. Disorders of the Cauda Equina. Continuum (Minneap Minn) 2021; 27:205-224. [PMID: 33522743 DOI: 10.1212/con.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Cauda equina dysfunction (often referred to as cauda equina syndrome) is caused by a diverse group of disorders that affect the lumbosacral nerve roots. It is important to recognize dysfunction of the cauda equina quickly to minimize diagnostic delay and lasting neurologic symptoms. This article describes cauda equina anatomy and the clinical features, differential diagnosis, and management of cauda equina disorders. RECENT FINDINGS The diagnosis of disorders of the cauda equina continues to be a challenge. If a compressive etiology is seen, urgent neurosurgical intervention is recommended. However, many people with clinical features of cauda equina dysfunction will have negative diagnostic studies. If the MRI is negative, it is important to understand the diagnostic evaluation and differential diagnosis so that less common etiologies are not missed. SUMMARY Cauda equina dysfunction most often occurs due to lumbosacral disk herniation. Nondiskogenic causes include vascular, infectious, inflammatory, traumatic, and neoplastic etiologies. Urgent evaluation and surgical intervention are recommended in most cases of compressive cauda equina syndrome. Other types of treatment may also be indicated depending on the etiology.
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Liddle DG, Changstrom B, Senter C, Meirick P, Stern N, Putukian M, Shah S, Powell A, Dixit S, Eerkes K, Moran B, Barnes KP, Dal Molin C, Myers R, Waterbrook AL. Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training. Curr Sports Med Rep 2021; 20:113-123. [PMID: 33560036 DOI: 10.1249/jsr.0000000000000811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
ABSTRACT Patients present to primary care physicians with musculoskeletal complaints more often than they do for upper respiratory infections, hypertension, or diabetes. Despite this, instruction in musculoskeletal medicine for internal medicine residents represents less than 1% of their total didactic and clinical education time. We recognize the immense breadth of knowledge and skill required to train residents in the practice of internal medicine. This curriculum guideline defines a recommended training strategy, and supplies relevant resources, to improve musculoskeletal education among internal medicine residents to optimize patient care. This curriculum guideline was created by internists who are sports medicine specialists. Sports medicine physicians promote overall health and well-being while providing expertise in acute and chronic musculoskeletal conditions, as well as how disease affects exercise and using exercise as medicine for people with chronic disease.
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Affiliation(s)
- David G Liddle
- Intermountain Sports Medicine, Intermountain Healthcare, Logan Regional Orthopedics and Sports Medicine, Logan, UT
| | - Bradley Changstrom
- Department of Medicine, Division of Internal Medicine, University of Colorado, Denver, CO
| | - Carlin Senter
- Department of Orthopaedic Surgery, Division of Sports Medicine, University of California San Francisco, San Francisco, CA
| | | | | | - Margot Putukian
- Princeton University, McCosh Health Center, University Health Services, Preinceton, NJ
| | - Selina Shah
- Center for Sports Medicine, Walnut Creek, CA
| | - Amy Powell
- Department of Orthopaedic Surgery and Department of Internal Medicine, Division of General Internal Medicine, University of Utah, Salt Lake City, UT
| | - Sameer Dixit
- Department of Primary Care Sports Medicine, Hospital for Special Surgery, New York, NY
| | - Kevin Eerkes
- NYU Langone Health, Department of Internal Medicine, New York University, New York, NY
| | - Byron Moran
- Department of Orthopaedic Surgery, Division of Sports Medicine, College of Medicine, University of South Florida, Tampa, FL
| | - Kenneth P Barnes
- Department of Orthopaedic Surgery, Division of Sports Medicine, Moses H. Cone Memorial Hospital, Greensboro, NC
| | - Claudia Dal Molin
- Department of Internal Medicine and Department of Orthopaedic Surgery, Division of Sports Medicine, University of Maryland, Baltimore, MD
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Crawford AM, Guild TT, Striano BM, Von Keudell AG. Spontaneous iliacus haematoma with femoral nerve palsy: an appeal to involve surgical teams early. BMJ Case Rep 2021; 14:14/1/e239024. [PMID: 33462039 PMCID: PMC7816894 DOI: 10.1136/bcr-2020-239024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
We report the case of a 68-year-old man who was placed on heparin as bridge therapy and subsequently developed an iliacus haematoma with associated femoral nerve palsy. His team involved the orthopaedic surgery team in delayed fashion after his symptom onset. Due to his active medical conditions, he did not undergo surgical decompression of his haematoma until late into his hospital course. Unfortunately, this patient did not regain meaningful function from his femoral nerve deficit. We believe this case highlights the high index of suspicion necessary for making this diagnosis as well as the repercussions of an untimely decompression for this acute, compressive neuropathy. Although we are surgeons and this is a surgical case, we hope to publish this case in a medical journal to raise awareness that surgical decompression does have a role in this diagnosis and should ultimately be pursued early in its course for optimal patient benefit.
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Affiliation(s)
| | - Theodore T Guild
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
| | - Brendan M Striano
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts, USA
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Implementation and Patient Satisfaction of Telemedicine in Spine Physical Medicine and Rehabilitation Patients During the COVID-19 Shutdown. Am J Phys Med Rehabil 2020; 99:1079-1085. [PMID: 32969967 DOI: 10.1097/phm.0000000000001600] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the implementation and patient satisfaction of telemedicine visits in a physical medicine and rehabilitation spine practice during COVID-19. DESIGN This is a prospective cohort study. RESULTS Of 172 patients, 97.6% were very satisfied or satisfied (83.7% of the patients were very satisfied) with their telemedicine appointment. In 44.4% of the cases, the physical medicine and rehabilitation physician prescribed medication to the patient, and in 21.6% of the cases, either an injection or radiofrequency ablation was ordered. Most patients (87%) did not have any issues during their encounter. Lastly, 64.5% of the patients preferred telemedicine over in-person appointments, whereas 56.1% of the patients who are 60 yrs and older responded the same. A total of 67.4% of those who had a follow-up visit would choose telemedicine over in-person. CONCLUSIONS The results of this study show that telemedicine can provide very effective and satisfactory care in a physical medicine and rehabilitation spine practice. This was especially notable with follow-up visits where imaging and treatment plan can easily be discussed over telemedicine. Stay-at-home orders and improved reimbursement during the COVID-19 pandemic have spurred adoption of telemedicine with high patient satisfaction. We hope that physical medicine and rehabilitation physicians will be able to continue expanding patient access in the postpandemic world.
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Wang H, Huo Y, Li L, Liu X, Yang D, Ding W, Yang S. Clinical Efficacy of Laminectomy with Instrumented Fixation in Treating Thoracolumbar Intradural Extramedullary Schwannomas: A Comparative Study. Med Sci Monit 2020; 26:e921719. [PMID: 32515362 PMCID: PMC7299065 DOI: 10.12659/msm.921719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background This study investigated the clinical effect of laminectomy plus pedicle screw fixation in treating thoracolumbar intradural extramedullary schwannomas. Material/Methods Between October 2011 and May 2017, 57 patients undergoing resection of thoracolumbar schwannomas were retrospectively identified and included in the study. Based on the surgical procedures used, all participants were assigned to either the laminectomy-only group (n=33) or the combination group (laminectomy plus pedicle screw fixation, n=24). All participants were followed up for over 2 years. In the laminectomy, the spinal process, vertebral laminae, and bilateral upper articular processes of the surgical segments were completely resected and the lower articular processes were reserved. For further analysis, we evaluated the pain levels using visual analogue scale (VAS) score. The assessment of neurological function was performed with Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI). The comparisons of Cobb angle changes were carried out pre-surgery and post-surgery. Results The demographic data were well matched between the laminectomy-only group and combination group, without significant differences (P>0.05). After surgery, both surgical procedures achieved significant improvement in VAS score, ODI, and JOA score (P<0.001), but no significant differences were found between these 2 surgical procedures (P>0.05). The postoperative change in Cobb angle indicated a significant difference in the laminectomy-only group, but not in the combination group (P<0.05). In addition, postoperative spinal instability/deformity was found in the laminectomy-only group (P<0.05). Conclusions In conclusion, the combination of laminectomy and pedicle screw fixation is a safe and effective surgical procedure when used to treat thoracolumbar schwannoma, and appears to be superior to the laminectomy-only procedure.
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Affiliation(s)
- Haoming Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Yachong Huo
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Liang Li
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Xiaobing Liu
- Department of Neurosurgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Dalong Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Wenyuan Ding
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Sidong Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
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Brouwers EMJR, Meent HVD, Curt A, Maier DD, Abel RF, Weidner N, Rupp R, Kriz J, de Haan AFJ, Kramer JK, Hosman AJF, Bartels RHMA. Recovery after traumatic thoracic- and lumbar spinal cord injury: the neurological level of injury matters. Spinal Cord 2020; 58:980-987. [DOI: 10.1038/s41393-020-0463-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 03/26/2020] [Accepted: 03/30/2020] [Indexed: 12/13/2022]
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Intervertebral Disc Diseases PART 2: A Review of the Current Diagnostic and Treatment Strategies for Intervertebral Disc Disease. Int J Mol Sci 2020; 21:ijms21062135. [PMID: 32244936 PMCID: PMC7139690 DOI: 10.3390/ijms21062135] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/12/2020] [Accepted: 03/18/2020] [Indexed: 12/25/2022] Open
Abstract
With an aging population, there is a proportional increase in the prevalence of intervertebral disc diseases. Intervertebral disc diseases are the leading cause of lower back pain and disability. With a high prevalence of asymptomatic intervertebral disc diseases, there is a need for accurate diagnosis, which is key to management. A thorough understanding of the pathophysiology and clinical manifestation aids in understanding the natural history of these conditions. Recent developments in radiological and biomarker investigations have potential to provide noninvasive alternatives to the gold standard, invasive discogram. There is a large volume of literature on the management of intervertebral disc diseases, which we categorized into five headings: (a) Relief of pain by conservative management, (b) restorative treatment by molecular therapy, (c) reconstructive treatment by percutaneous intervertebral disc techniques, (d) relieving compression and replacement surgery, and (e) rigid fusion surgery. This review article aims to provide an overview on various current diagnostic and treatment options and discuss the interplay between each arms of these scientific and treatment advancements, hence providing an outlook of their potential future developments and collaborations in the management of intervertebral disc diseases.
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Abstract
Lower back pain is a commonly reported symptom during pregnancy. However, herniated lumbar disk disease is an uncommon cause for such pain. Cauda equina syndrome (CES) during pregnancy is a rare clinical scenario. This review highlights the epidemiology, diagnostic and treatment strategies, and challenges encountered when managing herniated lumbar disk disease and CES in pregnancy. Magnetic resonance imaging is the diagnostic modality of choice. Nonoperative treatment strategies are successful in the vast majority of cases in patients with a herniated disk in the absence of CES. CES and progressive neurological deficits remain absolute indications for surgical intervention regardless of gestational age. For such patients or those with debilitating symptoms refractory to nonoperative treatment strategies, surgery has been demonstrated to be safe in the pregnant patient population. However, surgery should be performed with obstetric and midwifery support should complications occur to the fetus.
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Bladder Scans and Postvoid Residual Volume Measurement Improve Diagnostic Accuracy of Cauda Equina Syndrome. Spine (Phila Pa 1976) 2019; 44:1303-1308. [PMID: 31479434 DOI: 10.1097/brs.0000000000003152] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, observational cohort study. OBJECTIVE The aim of this study was to determine the role of pre and postvoid bladder scan in predicting cauda equina syndrome (CES). The thesis was that bladder scanning [specifically postvoid residual (PVR) volume] would have higher diagnostic accuracy than physical examination alone. SUMMARY OF BACKGROUND DATA CES is an ill-defined condition with a spectrum of presenting symptoms. There is neither a combination of clinical symptoms and/or signs that reliably predicts cauda equina compression nor single defining clinical criterion that has 100% predictive value to confirm or exclude CES. METHODS Patients with suspected CES admitted over a 6-month period at a single institution were prospectively assessed by physical examination (including digital rectal examination and pin prick perianal sensation) and bladder ultrasound scanning (recording pre- and PVR volume). These results were compared with the subsequent magnetic resonance imaging (MRI) scans and those patients who had emergent surgery for CES. RESULTS Ninety-two patients were included in the study (52 women) with a mean age of 44.9 years.An MRI scan demonstrating causing compression of the cauda equina was present in only 18% (17/92).The sensitivity of anal tone to predict CES was 52.9%. Peri-anal numbness (either unilateral or bilateral) had sensitivity of 82.3% and negative predictive value of 92%.For nonoperated group (without CES), mean PVR was 199 mL (95% confidence interval ± 59 mL). On the basis of receiver operating curves, the optimal bladder volume cut-off for predicting CES was ≥200 mL for PVR volume. A PVR of <200 mL gave CES probability of 3.6%. If >200 mL, then the probability of having CES is 43% (P < 0.000003). A PVR <200 mL had a negative predictive value of 97%. CONCLUSION Bladder scanning was a useful adjunct in the diagnosis of CES. It had a better negative predictive value than physical examination. LEVEL OF EVIDENCE 3.
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Benko MJ, Danison AP, Marvin EA, Saway BF. Distal Cauda equina syndrome: A case report of lumbosacral disc pathology and review of literature. Surg Neurol Int 2019; 10:84. [PMID: 31528422 PMCID: PMC6744781 DOI: 10.25259/sni-152-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/25/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cauda equina syndrome (CES) is an uncommon entity that presents acutely with all or some of the following symptoms; urinary incontinence from retention, fecal incontinence from loss of sphincter tone, saddle area hypoesthesia or anesthesia, and acute or progressive weakness in one or both lower extremities. The protean symptomatology is often mixed and is vulnerable to confounding comorbidities making the accurate and timely diagnosis of this syndrome uniquely challenging. Here, we present the case of a man who developed isolated sacral nerve dysfunction from CES in the midst of a diabetic crisis. CASE DESCRIPTION A 53-year-old male with a long history of uncontrolled Type 2 diabetes presented with acute-onset urinary and fecal incontinence, scrotal anesthesia, and a 3-day history of lower back pain with intermittent bilateral leg pain. This patient displayed no objective changes in leg strength, sensation, or reflexes. In addition, the patient tested positive for cocaine and had a blood glucose level of 800 mg/dL which confounded his clinical picture. The patient underwent bilateral laminectomies from L4-S1 with the removal of a large sequestered disc fragment from the S1-S2 disc space within 8 h of presentation with reasonable recovery. CONCLUSION Highly variable presentations often confound the accurate and timely diagnosis of CES with severe implications on quality of life. Despite the limited functional recovery seen after surgical decompression, urgent or emergent intervention is paramount for treatment. Our patient's presenting symptomatology and comorbidities highlight the need for practitioners to maintain a high index of suspicion in anyone with incontinence and back pain, regardless of distractors and even in the absence of other anticipated motor or sensory findings.
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Affiliation(s)
| | | | | | - Brian F. Saway
- Division of Neurosurgery, Virginia Tech Carilion School of Medicine Roanoke, Virginia, United States
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Moon MS, Jeong JH, Kim SJ, Kim MS, Choi WR. Magnetic Resonance Imaging Observations of the Conus Medullaris in a Korean Population. Asian Spine J 2018; 13:313-317. [PMID: 30567421 PMCID: PMC6454280 DOI: 10.31616/asj.2018.0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 08/12/2018] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective study (level of evidence: level 3). PURPOSE To study the anatomy of the conus medullaris in Koreans. OVERVIEW OF LITERATURE The anatomical position of the conus medullaris is well-documented in anatomy textbooks; however, the shape of the conus in the canal rarely described. Furthermore, to our knowledge, no study in Korea has not yet assessed the shape of the conus as well as its position in the canal via cadavaric dissection and/or magnetic resonance imaging (MRI). METHODS MRI findings of 189 Korean patients aged 2-94 years (93 men and 94 women) were assessed. No subjects from other ethnicities were included. The method proposed by Arai and colleagues was used to assess the termination point and shape of the conus in the canal. The position of the intervertebral disc trisection of the vertebral body closest to the tip of the conus was recorded at the canal level. RESULTS The tip of the conus medullaris was positioned from the upper T12 body to the L2-L3 disc, mostly in L1 bodies (52.4%), followed by the L2 bodies (22.5%), the L1-L2 disc, and the L2-L3 disc (1.1%). The shape of the conus was classified as type A in 74 (39.6%), type B in 58 (31%), and type C in 55 patients (29.4%). The conus did not terminate at the L3 body in any patient. In the first decade ones (five children) conus positioned rather lowly from L1 bodies to L2-L3 disc, and no type A conus shape, and mostly type B (80%). CONCLUSIONS The conus medullaris was positioned mostly in the lower one-third of L1 and it in the first decades terminated lowly. No type A in the first decade one, and type B was mostly frequently formed which was followed by type C.
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Affiliation(s)
- Myung-Sang Moon
- Department of Orthopedic and Traumatic Surgery, Cheju Halla General Hospital, Jeju, Korea
| | - Ji-Ho Jeong
- Department of Orthopedic and Traumatic Surgery, Cheju Halla General Hospital, Jeju, Korea
| | - Sang-Jae Kim
- Department of Orthopedic and Traumatic Surgery, Cheju Halla General Hospital, Jeju, Korea
| | - Min-Su Kim
- Department of Orthopedic and Traumatic Surgery, Cheju Halla General Hospital, Jeju, Korea
| | - Won-Rak Choi
- Department of Orthopedic and Traumatic Surgery, Cheju Halla General Hospital, Jeju, Korea
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Inoue T. Pure Conus Medullaris Syndrome without Lower Extremity Involvement Caused by Intradural Disc Herniation at L1/2: A Case Report. Spine Surg Relat Res 2018; 3:392-395. [PMID: 31768461 PMCID: PMC6834459 DOI: 10.22603/ssrr.2018-0032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 09/18/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction Conus medullaris syndrome (CMS) is a rare pathology. The conus medullaris is located at the end of the spinal cord and continues to the cauda equina. Conus medullaris lesions can cause variable symptoms and neurological deficits, usually involving the lower extremities; CMS that does not affect the lower limbs is extremely rare. No reports have described isolated CMS caused by intradural disc herniation (IDH). This report describes a case of CMS without lower extremity involvement associated with IDH at L1/2. Case Report A 52-year-old man with a 10-year history of lower back pain complained of dysuria and lumbago with no leg symptoms at his first visit to the urology department. Neurological examination revealed mild perineal hypoalgesia; however, motor function and lower extremity sensation were normal with except for left ankle dorsiflexion weakness (manual muscle test, 4/5). Magnetic resonance imaging revealed conus medullaris compression by a mass, continuous with the L1/2 disc, and severe spinal canal stenosis at vertebral levels L3/4 and L4/5. Postmyelographic computed tomography indicated direct conus medullaris compression by an intradural and extramedullary mass continuous with the L1/2 disc. Without recovery of his dysuria, the patient underwent surgery, including partial laminectomy of the L1/2, incision of the dura mater, and removal of the herniated disc. Immediately after surgery, his dysuria completely resolved. More than one year postoperatively, the patient remained active with no change in his neurological condition. Conclusions Although CMS without lower limb symptoms is extremely rare, we experienced an isolated case of CMS associated with IDH causing direct conus medullaris compression. Without lower extremity involvement, the CMS diagnosis was relatively easy. Surgical treatment for CMS without lower extremity involvement caused by IDH was effective.
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Affiliation(s)
- Tetsuji Inoue
- Department of Orthopaedic Surgery, Minamata City General Hospital and Medical Center, Minamata, Japan
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Abstract
Most lumbar intradural schwannomas present initially as radiculopathies with sensory disturbances. However, neurogenic bladder dysfunction may be one of the earliest manifestations and can cause long-term disability. We present the case of a patient with a L3-4 schwannoma (newly diagnosed owing to recurrent urinary retention and urinary tract infection) who finally underwent surgical resection. Improvement of bladder sensation was documented by urodynamic study and the patient was subsequently weaned off her Foley catheter with satisfactory outcome.
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Affiliation(s)
- KS Yang
- Department of Physical Medicine and Rehabilitation, Lotung Poh-Ai Hospital, Taiwan
| | - CS Ho
- Department of Physical Medicine and Rehabilitation, Lotung Poh-Ai Hospital, Taiwan
- Graduate Institute of Sports Science, National Taiwan Sport University, Taiwan
| | - PA Tai
- Department of Surgery, Taipei Tzu Chi Hospital and Buddhist Tzu Chi University, Taiwan
- PA Tai and WM Kung both contributed equally to this work as co-corresponding authors
| | - WM Kung
- Department of Surgery, Taipei Tzu Chi Hospital and Buddhist Tzu Chi University, Taiwan
- Department of Exercise and Health Promotion, Chinese Culture University, Taiwan
- PA Tai and WM Kung both contributed equally to this work as co-corresponding authors
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Cushnie D, Urquhart JC, Gurr KR, Siddiqi F, Bailey CS. Obesity and spinal epidural lipomatosis in cauda equina syndrome. Spine J 2018; 18:407-413. [PMID: 28756300 DOI: 10.1016/j.spinee.2017.07.177] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 07/09/2017] [Accepted: 07/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although lumbar disc herniations are common, only a small portion of these herniations lead to cauda equina syndrome (CES), which is an uncommon but debilitating disorder. Why some patients with herniation develop CES, when most do not, remains unknown. Preexisting subclinical epidural lipomatosis may limit canal space such that an otherwise benign herniation causes CES. PURPOSE This study determines whether patients with an acute disc herniation and CES have a greater body mass index (BMI) and greater quantity of epidural fat compared with control subjects with non-CES symptomatic lumbar herniated discs. STUDY DESIGN/SETTING A retrospective case-control series at a university-based level-1 trauma center was carried out. PATIENT SAMPLE There were 33 CES and 66 control subjects identified from a prospectively maintained database of patients who underwent surgical management for a lumbar disc herniation between 2007 and 2012. Each CES case had two non-CES control patients matched by gender and age within 5 years except 5 CES cases that matched only one non-CES control. OUTCOME MEASURES The outcome measures included weight, height, age, gender, and BMI. Radiographic outcome measures included the proportion of lumbar spinal canal occupied by fat and herniated disc on preoperative magnetic resonance imaging. METHODS Patient charts and preoperative radiographs were retrospectively reviewed. For each patient, a blinded reviewer determined the proportion of lumbar spinal canal occupied by fat, and the maximal proportion of the canal occupied by herniated material at the involved level. Patient demographics and radiographic measures were compared between CES and control groups using chi-square or Student t tests. A second blinded reviewer re-assessed a series of radiographs, and the intraobserver variability was determined by Spearman correlation. Logistic regression was used to model the preoperative factors associated with having an acute disc herniation and CES. RESULTS The CES cases had higher BMI (31.8 kg/m2, 95% confidence interval [CI] 29.5-34.0 vs. 28.1 kg/m2, 95% CI 26.7-29.5 in controls; p=.007), focally narrower canals (14.6 mm, 95% CI 13.8-15.3 mm vs. 16.4 mm, 95% CI 15.4-17.3 mm in controls; p=.003), and a greater percentage of spinal canal occupied by epidural fat (31.3%, 95% CI 26.1%-36.6% vs. 21.9%, 95% CI 18.7%-25.1% in controls; p=.003) and herniated disc material (54.5%, 95% CI 46.9%-62.0% vs. 34.4%, 95% CI 30.3%-38.5% in controls; p<.0001). Logistic regression confirmed canal width at the involved level, BMI, amount of canal occupied disc, and proportion of canal occupied by fat as independent predictors of having an acute disc herniation and CES. CONCLUSIONS Obesity is a risk factor for CES from disc herniation. The CES cases also had a greater amount of herniated material, focally narrower canal, and larger epidural fat deposits. The latter may be the mechanism linking obesity with CES.
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Affiliation(s)
- Duncan Cushnie
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, Ontario, Canada N6A 3K7; B London Spine Program, London Health Sciences Center, E1 317, 800 Commissioners Rd, London, Ontario, Canada N6A 5W9
| | - Jennifer C Urquhart
- B London Spine Program, London Health Sciences Center, E1 317, 800 Commissioners Rd, London, Ontario, Canada N6A 5W9; Lawson Health Research Institute, 750 Base Line Rd East, London, Ontario, Canada N6C 2R5
| | - Kevin R Gurr
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, Ontario, Canada N6A 3K7; B London Spine Program, London Health Sciences Center, E1 317, 800 Commissioners Rd, London, Ontario, Canada N6A 5W9; Lawson Health Research Institute, 750 Base Line Rd East, London, Ontario, Canada N6C 2R5
| | - Fawaz Siddiqi
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, Ontario, Canada N6A 3K7; B London Spine Program, London Health Sciences Center, E1 317, 800 Commissioners Rd, London, Ontario, Canada N6A 5W9; Lawson Health Research Institute, 750 Base Line Rd East, London, Ontario, Canada N6C 2R5
| | - Christopher S Bailey
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, Ontario, Canada N6A 3K7; B London Spine Program, London Health Sciences Center, E1 317, 800 Commissioners Rd, London, Ontario, Canada N6A 5W9; Lawson Health Research Institute, 750 Base Line Rd East, London, Ontario, Canada N6C 2R5.
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Cιftcι H, Ozgonul A, Sogut O, Savas M. Incomplete Cauda Equina Syndrome Presenting with Acute Urinary Retention in the Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791001700513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- H Cιftcι
- Harran University, Department of Urology, School of Medicine, Sanliurfa, Turkey
| | - A Ozgonul
- Harran University, Department of General Surgery, School of Medicine, Sanliurfa, Turkey
| | | | - M Savas
- Harran University, Department of Urology, School of Medicine, Sanliurfa, Turkey
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Kong QJ, Wang Y, Liu Y, Sun JC, Xu XM, Sun XF, Shi JG. Neuroprotective Effects of Valproic Acid in a Rat Model of Cauda Equina Injury. World Neurosurg 2017; 108:128-136. [PMID: 28867325 DOI: 10.1016/j.wneu.2017.08.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Histone deacetylase inhibitors, including valproic acid (VPA), are promising therapeutic interventions in neurological disorders and play an important role in synaptic activity and neuronal function. METHODS A total of 30 rats were randomly allocated to 3 groups: sham, control, and VPA. The rats in the VPA and control groups received laminectomy at the L4 level of the vertebrae and silicone gel implantation into the epidural spaces L5 and L6. Rats in the sham group only received laminectomy at the L4 level of vertebrae without any implantation. VPA (300 mg/kg in saline) was administered 2 hours before the surgery. After the surgery, the VPA group received further VPA injections at 300 mg/kg twice a day for 1 week. The same volume of saline was injected in the control group. Neurobehavioral tests using the Basso, Beattie, Bresnahan scale and the oblique board test were performed for 1 week starting at 2 hours before surgery up to day 7 after surgery. At day 7 after surgery, tissues from the compressed cauda equina (L5-L6) were subjected to hematoxylin and eosin, luxol fast blue, or immunofluorescence staining, whereas the terminal deoxynucleotidyl transferase-mediated biotinylated UTP nick-end label assay staining was performed on the tissue from the dorsal root ganglions and the lumbar segment of the spinal cord proximal to the compressed cauda equina (L5-L6). RESULTS The behavioral results suggested a significant improvement in the lower limb motor function in the VPA group compared with controls (P < 0.05). Furthermore, histologic assessment revealed a significant reduction in nerve fibers showing Wallerian degeneration and demyelinating lesions in the VPA group, in addition to an increased myelination compared with the control group (P < 0.05). The terminal deoxynucleotidyl transferase-mediated biotinylated UTP nick-end label assay staining revealed a significant decrease in the number of apoptotic neurons in the spinal cord anterior horn and dorsal root ganglions in the VPA group compared with controls (P < 0.05). CONCLUSIONS Our data demonstrated that VPA could alleviate cauda equina injury, reduce apoptotic cells, and improve motor recovery, suggesting a neuroprotective effect in acute cauda equina syndrome.
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Affiliation(s)
- Qing-Jie Kong
- Department of Spine Surgery, the Affiliated Changzheng Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Yuan Wang
- Department of Spine Surgery, the Affiliated Changzheng Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Yang Liu
- Department of Spine Surgery, the Affiliated Changzheng Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Jing-Chuan Sun
- Department of Spine Surgery, the Affiliated Changzheng Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Xi-Ming Xu
- Department of Spine Surgery, the Affiliated Changzheng Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Xiao-Fei Sun
- Department of Spine Surgery, the Affiliated Changzheng Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Jian-Gang Shi
- Department of Spine Surgery, the Affiliated Changzheng Hospital of the Second Military Medical University, Shanghai, People's Republic of China.
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Altschul D, Kobets A, Nakhla J, Jada A, Nasser R, Kinon MD, Yassari R, Houten J. Postoperative urinary retention in patients undergoing elective spinal surgery. J Neurosurg Spine 2017. [DOI: org/10.3171/2016.8.spine151371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
OBJECTIVE
Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence.
METHODS
The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis.
RESULTS
Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome.
CONCLUSIONS
Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.
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Shahmohammadi M, Khoshuod RJ, Zali A, Seddeghi AS, Kabir NM. Examination of The Predictive Power of Electromyography and Urodynamic Study in Patients with Cauda Equina Syndrome (Horse Tail Syndrome). Acta Inform Med 2017; 24:328-331. [PMID: 28077887 PMCID: PMC5203747 DOI: 10.5455/aim.2016.24.328-331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 10/12/2016] [Indexed: 11/20/2022] Open
Abstract
Background: Cauda equina syndrome is a rare disorder that causes loss of Lumbar plexus function (nerve roots) lower than conus medullaris. No risk factor has been defined for this disease yet. Due to the high morbidity of Cauda equina syndrome and lack of sufficient information about the connection between the disease and urodynamic findings and EMG (Electromyography) findings, the need for this comprehensive study is felt. Objective: The aim is to determine the predictive power of findings resulted from urodynamics and electromyography of perineal region and around sphincter in the clinical cure rate of urination in patients with urinary retention followed by Cauda equina syndrome. Method: Patients referred to Shohadaye Tajrish Hospital during the years 2009 to 2013, in case of having Cauda equina syndrome symptoms (confirmed with Lumbar MRI), were undergone urodynamic examination and perineal electromyography after surgical decompression action. These both assessments (urodynamic study and electromyography) were repeated during the follow-up of 15 patients in the first and sixth months after surgery and findings were compared with each other. Results: Among the Urodynamic findings, Qmax (maximum urine flow) during three studies had a significant relationship with long-term recovery rate of patients (P <0.05). The relationship had been more valuable in follow-ups after one month (P = 0.0001). Also, BCI (Bladder Contractility Index) in all three studies had a significant relationship with clinical improvement in the ability to urinate (P <0.001). The residual urine (PVR) compared to two previous urodynamic findings showed a less significant relationship with clinical cure rate (P = 0.04). Among the findings of muscle-nerve (MUAP Fibrillation, Positive sharp way) none of them had a significant relationship with cure rate. Conclusion: Urodynamic finding, especially Qmax and bladder contractility index, can be considered as predictive indicators for patients’ recovery after surgery.
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Affiliation(s)
- Mohammadreza Shahmohammadi
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellent, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Jalil Khoshuod
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellent, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Zali
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellent, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Saied Seddeghi
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellent, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nima Mohseni Kabir
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellent, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Altschul D, Kobets A, Nakhla J, Jada A, Nasser R, Kinon MD, Yassari R, Houten J. Postoperative urinary retention in patients undergoing elective spinal surgery. J Neurosurg Spine 2016; 26:229-234. [PMID: 27767680 DOI: 10.3171/2016.8.spine151371] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence. METHODS The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis. RESULTS Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome. CONCLUSIONS Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.
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Affiliation(s)
- David Altschul
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Andrew Kobets
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Jonathan Nakhla
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Ajit Jada
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Rani Nasser
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Merritt D Kinon
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - Reza Yassari
- Department of Neurosurgery, Montefiore Medical Center and Albert Einstein College of Medicine of Yeshiva University, Bronx, New York; and
| | - John Houten
- Marcus Neuroscience Institute, Boca Raton, Florida
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Acute-onset arachnoid cyst causing cauda equina compression after uneventful lumbar decompression and fusion. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nater A, Fehlings MG. The Timing of Decompressive Spinal Surgery in Cauda Equina Syndrome. World Neurosurg 2015; 83:19-22. [DOI: 10.1016/j.wneu.2014.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/07/2014] [Indexed: 10/25/2022]
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Aly TA, Aboramadan MO. Efficacy of delayed decompression of lumbar disk herniation causing cauda equina syndrome. Orthopedics 2014; 37:e153-6. [PMID: 24679201 DOI: 10.3928/01477447-20140124-18] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 08/20/2013] [Indexed: 02/03/2023]
Abstract
Cauda equina syndrome (CES) is a rare but serious neurosurgical emergency that can have devastating long-lasting neurologic consequences. Compression of the cauda equina can result in paralysis of bowel and bladder function. Such compression has been considered the only absolute indication for surgery in cases of lumbar disk disease. Therefore, it is extremely important that physicians be aware of the condition so that a surgeon is consulted before neurological damage becomes permanent. This article reports the results of delayed surgical decompression in cases of lumbar disk herniation with CES. The study group comprised 14 patients (11 men and 3 women) with a mean age of 48 years (range, 36-57 years). Clinical presentation was chronic low back pain, sciatica, and impaired sphincter function. All patients had a fenestration at the affected level and site, and the disk fragments were excised and the disk space cleared. The surgeries were performed 1 to 3 months after onset of sphinctric disturbance. Postoperatively, all patients were relieved of back and/or leg pain and showed sensory improvement. Twelve patients regained full control of urination and defecation. Lower extremity strength improved in 9 patients. The classical presentation of CES is not obvious. Even if surgery is performed late due to delayed presentation, significant improvement in neurologic and bladder function can still be expected.
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Agarwal N, Shah J, Hansberry DR, Mammis A, Sharer LR, Goldstein IM. Presentation of cauda equina syndrome due to an intradural extramedullary abscess: a case report. Spine J 2014; 14:e1-6. [PMID: 24331844 DOI: 10.1016/j.spinee.2013.09.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 08/12/2013] [Accepted: 09/19/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Cauda equina syndrome is caused by compression or injury to the nerve roots distal to the level of the spinal cord. This syndrome presents as low back pain, motor and sensory deficits in the lower extremities, and bladder as well as bowel dysfunction. Although various etiologies of cauda equina syndrome have been reported, a less common cause is infection. PURPOSE To report a case of cauda equina syndrome caused by infection of an intradural extramedullary abscess with Staphylococcus aureus. STUDY DESIGN/SETTING Case report and review of the literature. METHODS The literature regarding the infectious causes of cauda equina syndrome was reviewed and a case of cauda equina syndrome caused by infection of an intradural extramedullary abscess with Staphylococcus aureus was reported. RESULTS A 37-year-old woman, with history of intravenous drug abuse, hepatitis C, and hepatitis B, presented with low back pain lasting 2 months, lower extremity pain, left greater than right with increasing weakness and difficulty ambulating, and urinary and fecal incontinence. Her presentation was consistent with cauda equina syndrome. The patient underwent a T12-L2 laminectomy, and intradural exploration revealed an abscess. Methicillin-resistant Staphylococcus aureus was found on wound culture. CONCLUSIONS Cauda equina syndrome, presenting as a result of spinal infection, such as the case reported here, is extremely rare but clinically important. Surgical intervention is generally the recommended therapeutic modality.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 8100, PO Box 1709, Newark, NJ 07101-1709, USA
| | - Janki Shah
- Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 8100, PO Box 1709, Newark, NJ 07101-1709, USA
| | - David R Hansberry
- Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 8100, PO Box 1709, Newark, NJ 07101-1709, USA
| | - Antonios Mammis
- Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 8100, PO Box 1709, Newark, NJ 07101-1709, USA
| | - Leroy R Sharer
- Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 8100, PO Box 1709, Newark, NJ 07101-1709, USA
| | - Ira M Goldstein
- Department of Neurological Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 8100, PO Box 1709, Newark, NJ 07101-1709, USA.
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Lin MS, Lin HY, Hung KS, Lin TJ, Wang YC, Chiu WT, Kung WM. Seat belt syndrome with cauda equina syndrome: two unique cases in the same motor vehicle accident. Spine (Phila Pa 1976) 2013; 38:E1624-7. [PMID: 24026149 DOI: 10.1097/01.brs.0000435023.57940.43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE To describe the surgical technique and outcome of 2 cases of lap-shoulder belt injury involving burst fracture at L5 and cauda equina syndrome (CES). SUMMARY OF BACKGROUND DATA Lap-shoulder belts have largely replaced lap belts in the front seats of cars, and therefore the concept of seat belt injury needs re-evaluation. METHODS Two adults, the driver and front seat passenger in the same car involved in a collision, sustained lap-shoulder belt injury. One developed L5 Denis type A burst fracture and the other developed L5 Denis type B burst fracture. Both had CES. They were surgically managed by decompression of the spinal canal, which included removal of retropulsed fragments without impacting them. Both patients received short-segment transpedicle screws and rod system instrumentation without the fractured vertebra being included. RESULTS The percentage of preoperative degree of canal displacement of the retropulsed fragment was 60% in one patient and 55% in the other based on computed tomography. The mechanism of injury in both patients might be axial loading. After surgical intervention, the CES including lower leg weakness/numbness and bladder/bowel dysfunction clinically improved in both patients. CONCLUSION Two adults in the same car involved in a collision were wearing lap-shoulder belts, and 1 had Denis type A burst fracture at L5 and the other had Denis type B burst fracture at L5. Both developed CES after the accident. Both patients had a good clinical outcome after surgical treatment.
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Affiliation(s)
- Muh-Shi Lin
- *Department of Neurosurgery, Taipei City Hospital, Zhong Xiao Branch, Taipei, Taiwan †Department of Surgery, Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan ‡Department of Neurosurgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan §Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan ¶Department of Emergency, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan ‖Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan **Department of Exercise and Health Promotion, College of Education, Chinese Culture University, Taipei, Taiwan ††Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan; and ‡‡Department of Neurosurgery, Lo-Hsu Foundation, Lotung Poh-Ai Hospital, Luodong, Yilan, Taiwan
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Cauda equina syndrome caused by epidural pneumorrhachis: treatment with percutaneous computed tomography-guided translaminar trephination. Spine (Phila Pa 1976) 2013; 38:E440-3. [PMID: 23324943 DOI: 10.1097/brs.0b013e318286be7f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report and review of the literature. OBJECTIVE To present a rare case, and its treatment, of cauda equina syndrome (CES) caused by epidural pneumorrhachis after repeated caudal epidural injections. SUMMARY OF BACKGROUND DATA Pneumorrhachis is defined as the presence of air in the epidural or subarachnoid space. Epidural pneumorrhachis is usually asymptomatic and managed conservatively, but rare cases of lumbar radiculopathy resulting from epidural air have been reported. To the best of our knowledge, there has been no previous report of CES caused by epidural air. METHODS A 63-year-old male presented with recent aggravation of a low backache, with pain radiating to both lower limbs. He also complained of newly developed numbness in the buttocks, groins, and perineum, and difficulty with urination and defecation, after repeated caudal epidural injections during a 3-week period. Computed tomography and magnetic resonance imaging revealed epidural pneumorrhachis compressing the lumbar dural sac at the L2-L3 and L3-L4 levels. The patient's symptoms persisted despite 3 days of oxygen inhalation therapy. Attempted needle aspiration of the epidural air was unsuccessful and percutaneous computed tomography-guided translaminar trephination was performed. RESULTS The day after trephination, the patient's lower extremity motor strength began to improve; sphincter dysfunction began to resolve on the second day. During 8 weeks, his pain resolved and he gradually regained sensation. Two years later, the patient was free of symptoms or signs of CES. CONCLUSION Epidural pneumorrhachis may cause dural sac compression, thus worsening a patient's previous symptoms and possibly eliciting new problems such as CES. Conservative treatment should be the first-line approach, but surgery is often necessary when the problem remains unsolved. Percutaneous computed tomography-guided translaminar trephination may be an alternative to surgical decompression of the epidural space in selected patients.
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Venkatesan M, Uzoigwe CE, Perianayagam G, Braybrooke JR, Newey ML. Is cauda equina syndrome linked with obesity? ACTA ACUST UNITED AC 2013; 94:1551-6. [PMID: 23109638 DOI: 10.1302/0301-620x.94b11.29652] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No previous studies have examined the physical characteristics of patients with cauda equina syndrome (CES). We compared the anthropometric features of patients who developed CES after a disc prolapse with those who did not but who had symptoms that required elective surgery. We recorded the age, gender, height, weight and body mass index (BMI) of 92 consecutive patients who underwent elective lumbar discectomy and 40 consecutive patients who underwent discectomy for CES. On univariate analysis, the mean BMI of the elective discectomy cohort (26.5 kg/m2 (16.6 to 41.7) was very similar to that of the age-matched national mean (27.6 kg/m2, p = 1.0). However, the mean BMI of the CES cohort (31.1 kg/m2 (21.0 to 54.9)) was significantly higher than both that of the elective group (p < 0.001) and the age-matched national mean (p < 0.001). A similar pattern was seen with the weight of the groups. Multivariate logistic regression analysis was performed, adjusted for age, gender, height, weight and BMI. Increasing BMI and weight were strongly associated with an increased risk of CES (odds ratio (OR) 1.17, p < 0.001; and OR 1.06, p < 0.001, respectively). However, increasing height was linked with a reduced risk of CES (OR 0.9, p < 0.01). The odds of developing CES were 3.7 times higher (95% confidence interval (CI) 1.2 to 7.8, p = 0.016) in the overweight and obese (as defined by the World Health Organization: BMI ≥ 25 kg/m2) than in those of ideal weight. Those with very large discs (obstructing > 75% of the spinal canal) had a larger BMI than those with small discs (obstructing < 25% of the canal; p < 0.01). We therefore conclude that increasing BMI is associated with CES.
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Affiliation(s)
- M Venkatesan
- University Hospitals of Leicester, Department of Orthopaedics, Infirmary Square, Leicester LE1 5WW, UK.
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Shivji F, Tsegaye M. Cauda equina syndrome: the importance of complete multidisciplinary team management. BMJ Case Rep 2013; 2013:bcr-2012-007806. [PMID: 23505270 DOI: 10.1136/bcr-2012-007806] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A 44-year-old lady with a history of lumbar back pain presented to the emergency department complaining of severe back pain radiating to her buttocks. Positive examination findings were a loss of sensation in the perianal area and 348 ml of retained urine. An urgent MRI showed compression of the cauda equina by a herniated disc. The patient was operated upon that evening, having a lumbar 5/sacral 1 decompression and sequestrectomy. During follow-up, the patient was reviewed by a consultant spinal surgeon, a urologist and our cauda equina nurse at every appointment, as per the cauda equina pathway specifically designed and implemented by our spinal unit. This report shows the complex nature of cauda equina syndrome and broad functional deficit patients can suffer from. It shows the benefits of prompt diagnosis and surgery, together with intensive, multidisciplinary follow-up and treatment, all of which are possible by a specially created, cauda equina protocol.
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Affiliation(s)
- Faiz Shivji
- Department of Trauma & Orthopaedics, Queen's Medical Centre, Nottingham, UK.
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Complaints of micturition, defecation and sexual function in cauda equina syndrome due to lumbar disk herniation: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:1019-29. [PMID: 23238848 DOI: 10.1007/s00586-012-2601-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/29/2012] [Accepted: 11/20/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Cauda equina syndrome (CES) is a rare complication of lumbar disk herniation. Although micturition, defecation and/or sexual function are by definition affected, little seems to be known about long-term outcome. Aim of this study is to review current literature on outcome of micturition, defecation and sexual function in CES due to lumbar disk herniation. METHODS A literature search was done in Pubmed, Embase and Web of Science using a sensitive search string combination. Studies were selected by predefined selection criteria and risk of bias was assessed using a Cochrane checklist adjusted for this purpose. RESULTS Fifteen studies were included. Risk of bias varied with six studies showing low risk. Mean minimal follow-up time was 17.0 months (range 3-24 months). All studies evaluated micturition and reported dysfunction at follow-up in 42.5% (range 13.3-90.0%). Defecation and sexual function were evaluated in eight and nine studies, respectively, and reported to be 49.6 (range 10.5-90.0%) and 44.3% (range 10.0-76.6%), respectively. Only two studies assessed sexual function in all patients at follow-up. CONCLUSION This review offers an insight into the extent of micturition dysfunction, defecation dysfunction and sexual dysfunction (SD) in CES after decompression. Our findings show that dysfunction is extremely common, even at long-term follow-up. A condition as invalidating as CES requires proper patient information and the outcomes presented here may help in providing those data. Bias in included studies, lack of universal definitions and incomplete follow-up results qualify these data as the best we momentarily have, but still subject to improvement. Since SD seems to be severely underreported, we recommend further research to explore the extent of this problem, as well as the use of questionnaires in future clinical (prospective) studies to accomplish a more patient-based approach.
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