Cauda equina syndrome: what is the relationship between timing of surgery and outcome?

Abstract

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.

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

“…The incidence of CES among patients being operated on for herniated disc was relatively high in this study: 10.8% compared to 1-3% in literature [9,17]. This high incidence can be explained by the fact that the LUMC serves as a referral hospital for urgent neurosurgical cases.…”

Letter to the editor concerning “Cauda Equina Syndrome treated by surgical decompression: the influence of timing on surgical outcome” by A. Qureshi, P. Sell (2007) Eur Spine J 16:2143–2151

“…It is important to distinguish between patients who have an incomplete cauda equina syndrome (CESl) and patients who have a cauda equina syndrome with neurogenic retention of urine (CESR) [1,2]. In the absence of a complication of surgery, any neurological function that has not been lost, at the point of decompressive surgery, will not be lost.…”

“…There is controversy in the literature, to which Qureshi and Sell have referred. Broadly speaking we can identify three positions from the literature: (1) once the bladder is paralysed surgical decompression will lead to improvement in function in a proportion of patients but when the decompression is performed is not a determinant of outcome [1,2], (2) if surgical decompression is achieved within 24 h of CESR better outcomes are obtained than surgery delayed beyond 24 h [4,5] and (3) the window of opportunity extends to 48 h [6]. These conflicting views from the literature can be condensed into two potential principles: the first is a principle that there is a timedependant relationship between recovery of bladder function after CESR and when the decompression is performed (even if we are not entirely sure when any window of opportunity may close); in which case surgery should be performed as soon as practically possible.…”

Cauda equina syndrome: a review of the current clinical and medico-legal position

“…When the syndrome is incomplete (CES-Incomplete), the patient has urinary difficulties of neurogenic origin including altered urinary sensation, loss of desire to void, poor urinary stream and the need to strain in order to micturate [16]. Saddle and genital sensory deficit is often unilateral or partial and trigone sensation should be present.…”

“…Although the above description is clinically useful, in medico-legal and also clinical terms the important distinction is whether, at any given time, CES is complete or incomplete in relation to urinary function and perineal sensation [16]. A useful test, not generally described, is the test for trigone sensitivity in which an inflated Foley catheter is gently pulled with the patient unaware [47].…”