Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life

Abstract

Objective: Cauda equina syndrome (CES) is a feared complication of lumbar disc herniation. It is generally accepted that CES requires decompression within 6 hours of symptom onset, but this time goal is rarely met, and the relative benefit of delayed decompression on functional status and quality of life (QOL) remains unknown. The study objective was to describe the functional status and quality of life outcomes for patients who undergo delayed surgical decompression for CES. Methods: Patients with CES who underwent decompression of a herniated lumbar disc during a 10-year period were assessed at hospital discharge and at least 4 months after the procedure. Evaluation of functional outcomes was based on a previously validated scale and QOL outcomes on the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire. Results: During the study period, 1100 patients with herniated discs were identified, and 14 underwent surgical decompression for CES. All 14 had had symptoms for more than 38 hours before surgery. Ten patients were available for long-term follow-up. There was a strong correlation between long CES symptom duration and poor functional outcome: of 8 patients with symptoms for less than 10 days before decompression (range, 1.6-7.5 d), all had good functional outcomes. The 2 patients with more prolonged symptoms (10.6 and 14.2 d) had poor outcomes. SF-36 scores demonstrated declines in physical roles (p = 0.03), social function (p = 0.03) and increased pain (p = 0.003) compared with population norms. Correlation between SF-36 domain scores and CES symptom duration failed to achieve statistical significance, perhaps because of small sample size. Conclusions: Patients who undergo delayed decompression for CES have increased pain and impaired social and physical function. Longer delays correlate with worse functional outcomes. Beyond 24 hours, decompression delay may be associated with a poorer quality of life but, because of the rarity of CES, the sample size in this study was too small to provide definitive conclusions. Since no patients underwent surgery within 38.4 hours of symptoms, it is not possible to comment on the importance of emergent decompression in early presenters. RÉSUMÉObjectif : Le syndrome de la queue de cheval (SQC) est une complication redoutée de l'hernie discale lombaire. Il est généralement reconnu que ce syndrome nécessite une décompression dans les six heures suivant l'apparition des symptômes, mais ce délai-cible est rarement respecté et les bienfaits relatifs d'une décompression retardée du point de vue fonctionnel et de la qualité de vie demeurent inconnus. L'objectif de cette étude était de décrire le devenir de patients soumis à une EM ADVANCES • PROGRÈS DE LA MU

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

“…Previously, meta-analyses have displayed better outcomes with decompression taking place within 48 h [12,14] or within 36 h [13]. Some studies with smaller patient numbers display a significant better outcome after earlier decompression as well, with significant better outcomes with decompression within 48 h [9] and even after 10 days [4]. Studies displaying no difference in outcome are a minority and evaluate relative small patient numbers only [10,11].…”

“…In the last decades, especially the topic of timing of decompression and its relation to outcome has gained much attention in literature, with several small studies showing better-albeit not always significant-outcomes after the early decompression [4][5][6][7][8][9]. Other studies could not demonstrate a better outcome after early decompression [10,11].…”

Cauda Equina Syndrome Due to Lumbar Disc Herniation: a Review of Literature

“…19,24,25,30,41 The MRI is the fi rst clinical examination in the spinal cord for the patients who present the symptoms of CES. 5,15,18,20,42,43 Lumbar disc herniation, tumor, hematoma and infection are illustrated in the MRI. In the infection or in the neoplastic etiology of CES, the administration of intravenous contrast offers more detail in the imaging.…”

“…CES due to LDH is 1-3% of all disc herniations. [8][9][10][11][12][13][14][15][16][17] There are also other causes that lead to CES such as an accident that injured the spine, complications with spinal anesthesia, drug side effects and vascular lesions of the spinal cord. 5,9,18,19 Patients usually present symptoms such as low back pain with unilateral or bilateral sciatica, reduced sensation in the saddle area, reduction of sexual function, fecal incontinence, bladder dysfunction, muscular weakness in legs and sensory loss in the perineum, buttocks and upper posterior thighs.…”

Medical Screening and Evacuation: Cauda Equina Syndrome in a Combat Zone

“…CES is a rare, potentially devastating disorder that may arise from an acute disc herniation and is considered a true neurologic emergency. 8,45,48 The estimated prevalence of CES is 0.04% of all patients presenting with a primary complaint of LBP, 11,15,45 and it is most prevalent in the fourth or fifth decade of age. 43,45 CES occurs in 1% to 2% of all lumbar disc herniations that progress to surgery.…”