Does the Surgical Timing and Decompression Alone or Fusion Surgery in Lumbar Stenosis Influence Outcome in Cauda Equina Syndrome?

Abstract

Study Design A retrospective comparative analysis of 64 patients with cauda equina syndrome (CES), who underwent either decompression alone (NF) or fusion (F) surgery. Purpose We compared the outcomes and timing effects. Overview of Literature CES can cause loss of autonomic control of vesicular function and lower limb neurological deficits. Prompt diagnosis and emergency surgery markedly improve outcome. Although decompression only is a mainstream technique, there is guarded recovery of vesicular dysfunction. Decompression ventrally in a narrow window requires manipulation of neural tissue in an already jeopardised critical canal and may accentuate irreversible damages. In F surgery, the adequate exposure leads to a lower neural manipulation. Methods Until January 2008, we treated CES with decompression (laminectomy and/or discectomy). However, from that month forward, all our single-level CES patients have received a fusion operation. In this study, characteristic categorical variables and outcomes were analysed. Results In a retrospective analysis of 64 patients, NF (n=37) and F (n=27) who received treatment, we found that both groups improved significantly on follow-up in all objective parameters. Although, the comparison of clinical and functional outcome data between the two groups was statistically insignificant, the average value of objective outcome such as vesicular function, low back pain (LBP), and complications was better for patients in F group compared with NF group. However, the patient satisfaction for the F group was also lower, in view of their residual symptoms and disabilities. Contrary to common perceptions, we found that the timing of surgery does not influence the recovery rate for either approach. Conclusions Although both the techniques appear to be equally effective, the fusion approach overall showed a definite edge over non-fusion, with respect to reduced incidence of iatrogenic dural tears, LBP, and overall outcome, even despite the lower patient satisfaction.

Cauda Equina Syndrome: A Review of 15 Patients Who Underwent Percutaneous Transforaminal Endoscopic Lumbar Discectomy (PTELD) Under Local Anaesthesia

“…The first was CESI (incomplete), in which patients had a spectrum of urinary difficulties such as hesitancy, straining, low-pressure stream, and/or increased frequency. The second was CESR (with retention) 6 . Ultrasonographic measurement of post-void residual (PVR) urine was done in all CESR patients with measurement of more than 200ml considered positive 18 .…”

“…Sexual dysfunction scoring: Sexual dysfunction scoring on the basis of the SHIM (Sexual Health Inventory in Males) and a non-validated questionnaire to assess female sexual dysfunction was collected as a follow-up only. The SHIM is a five-item questionnaire validated as a screening tool for erectile dysfunction 6 , 19 . However, in conservative societies like India, a woman is expected to maintain silence when confronted with issues of her own sexuality.…”

“…So, instead of available validated female sexual dysfunction scores, we used a non-validated self-assessment questionnaire. The females were asked to give an overall score to categorise their sexual function as good, fair, or poor considering factors of frequency, satisfaction, dryness, and pain 6 .…”

“…Overall satisfaction: Patient Satisfaction Index was used as a self-assessment tool to determine the overall satisfaction outcome with 3 parameters - one highly satisfied, two moderately satisfied, and three not satisfied 6 . The quality of residual LBP was categorised into NILBP (non-instability LBP) and ILBP (instability-related LBP).…”

“…Although minimally invasive approaches have been reported, they are often not recommended due to perceived manipulations required in a smaller approach. Additionally, there are high chances of residual disabilities of limb and/or bladder and/or sexual dysfunction leading to unhappiness and medico-legal litigations 3 , 6 .…”