The role of urgent surgery in improving the outcome of cauda equina compression following lumbar central disc prolapse remains controversial. Some series claim improved outcome from emergency decompression whilst others have found no benefit. Resolution of this issue is important because the opportunity to reverse neurological impairment may already have been lost by the time of hospital admission. Removal of a large central disc prolapse can be considerably more difficult than routine discectomy, and may require an extensive exposure. When performed under less than optimal conditions, as often exists in the emergency setting, surgery may even add to rather than alleviate morbidity. This article reviews the pathophysiology of cauda equina syndrome, its definition, and the controversies surrounding management. Where urinary retention with overflow incontinence extists at presentation we believe that urgent decompression confers no benefit.
Questionnaires concerning the incidence of memory failures in everyday life were used in a postal survey of the aftereffects of severe head injury. Several years after a severe injury, 50 patients were compared to 33 patients a similar period after a very mild injury. A questionnaire completed on behalf of each patient by someone living in daily contact with him appeared to have some validity as a memory measure. The pattern of memory failures reported was similar to that found in a previous study and this may primarily reflect the ease with which certain forms of memory failure can be observed. A questionnaire completed by the patients themselves had little validity, possibly because severely injured patients could not recall their own memory failures. Only a minority of severely injured patients were reported to be significantly handicapped by memory failures at this stage in their recovery.
From a retrospective review of 932 patients undergoing surgery for prolapsed lumbar intervertebral disc a group of 33 cases with acute urinary retention was studied. There was no identifiable factor which predisposed this subgroup of patients to cauda equina compression. The mean duration of bladder paralysis prior to operation was 3.6 days. Ultimately almost 79% of patients claimed full recovery of bladder function, but only 22% were left without sensory deficit in the limbs or perineum. There was no correlation between recovery and the duration of bladder paralysis before surgery, except in three patients in whom there was no sciatica and where the correct diagnosis was delayed for many days. Retention developing less than 48 h after an acute prolapse was associated with a poorer prognosis. Despite claims that bladder paralysis should be treated with the same urgency as an extradural haematoma, there is no evidence in this study or in the literature to support the view that emergency surgery has any bearing upon the degree of clinical recovery. The exception may be if decompression can be undertaken within 6 h, the time estimated for axonal ischaemia to become irreversible. This should not however engender complacency in the management of this condition, which still requires prompt treatment. Whilst any apparent delay to surgery may have medicolegal implications should the patient fail to recover completely, in the majority of cases the die is cast at the time the prolapse occurs.
A total of 113 cases of open myelomeningocele operated on shortly after birth were followed up and the 80 survivors (71%) were assessed one and a quarter to seven and a half years later. Their disability was classified in terms of mobility, intelligence, continence, and major complications; these when combined provided an assessment of overall disability. The overall disability of the survivors was minimal in 6%, moderate in 40%, severe in 39%, and very severe in 15%.A number of clinical features present at birth were analysed for their predictive value. Of these the sensory level, which frequently differed from both external and radiological levels of the lesion, correlated with the outcome in terms of mobility, intelligence, continence, major complications, and overall disability; and also with deaths caused by renal failure.A policy of confining operation to those patients with a reasonable chance of achieving independence would involve selecting for treatment a minority of all infants born with open myelomeningocele.
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