Early intervention in cauda equina syndrome associated with better outcomes: a myth or reality? Insights from the Nationwide Inpatient Sample database (2005–2011)

Thakur, Jai Deep; Storey, Christopher; Kalakoti, Piyush; Ahmed, Osama; Dossani, Rimal H; Menger, Richard; Sharma, Kanika; Sun, Hai; Nanda, Anil

doi:10.1016/j.spinee.2017.04.023

Cited by 32 publications

(25 citation statements)

References 28 publications

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“…The GEE model as compared with the traditional logit model is superior in adjusting for clustering outcomes by hospitals 22,25,40,58 and has been used in previous studies involving administrative databases. 27,49,52 Metric end points (hospitalization cost and LOS) were modeled using an ordinary least squares (OLS) regression. Prior to modeling cost data, initial data exploration demonstrated a considerable degree of non-gaussian distribution.…”

Section: Discussionmentioning

confidence: 99%

Adolescent idiopathic scoliosis: risk factors for complications and the effect of hospital volume on outcomes

Menger

Kalakoti

Pugely

et al. 2017

Neurosurgical Focus

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OBJECTIVEAdolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Limited literature exists defining risk factors associated with outcomes during initial hospitalization in these patients. In this study, the authors investigated patient demographics, clinical and hospital characteristics impacting short-term outcomes, and costs in adolescent patients undergoing surgical deformity correction for idiopathic scoliosis. Additionally, the authors elucidate the impact of hospital surgical volume on outcomes for these patients.METHODSUsing the National Inpatient Sample database and appropriate International Classification of Diseases, 9th Revision codes, the authors identified adolescent patients (10–19 years of age) undergoing surgical deformity correction for idiopathic scoliosis during 2001–2014. For national estimates, appropriate weights provided by the Agency of Healthcare Research and Quality were used. Multivariable regression techniques were employed to assess the association of risk factors with discharge disposition, postsurgical neurological complications, length of hospital stay, and hospitalization costs.RESULTSOverall, 75,106 adolescent patients underwent surgical deformity correction. The rates of postsurgical complications were estimated at 0.9% for neurological issues, 2.8% for respiratory complications, 0.8% for cardiac complications, 0.4% for infections, 2.7% for gastrointestinal complications, 0.1% for venous thromboembolic events, and 0.1% for acute renal failure. Overall, patients stayed at the hospital for an average of 5.72 days (median 5 days) and on average incurred hospitalization costs estimated at $54,997 (median $47,909). As compared with patients at low-volume centers (≤ 50 operations/year), those undergoing surgical deformity correction at high-volume centers (> 50/year) had a significantly lower likelihood of an unfavorable discharge (discharge to rehabilitation) (OR 1.16, 95% CI 1.03–1.30, p = 0.016) and incurred lower costs (mean $33,462 vs $56,436, p < 0.001) but had a longer duration of stay (mean 6 vs 5.65 days, p = 0.002). In terms of neurological complications, no significant differences in the odds ratios were noted between high- and low-volume centers (OR 1.23, 95% CI 0.97–1.55, p = 0.091).CONCLUSIONSThis study provides insight into the clinical characteristics of AIS patients and their postoperative outcomes following deformity correction as they relate to hospital volume. It provides information regarding independent risk factors for unfavorable discharge and neurological complications following surgery for AIS. The proposed estimates could be used as an adjunct to clinical judgment in presurgical planning, risk stratification, and cost containment.

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Section: Discussionmentioning

confidence: 99%

Adolescent idiopathic scoliosis: risk factors for complications and the effect of hospital volume on outcomes

Menger

Kalakoti

Pugely

et al. 2017

Neurosurgical Focus

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“…Finally, when considering surgical intervention for this specific pathology of the lumbar spine, Tan et al reported three successful cases of patients who suffered from CES who were successfully treated via the anterior approach with lumbar discectomy [17]. However, regardless of approach, early intervention for patients with complete or incomplete CES is necessary and associated with successful clinical outcomes with minimal neurological loss [18]. For our case, the presentation represented a challenge from a surgical standpoint.…”

Section: Discussionmentioning

confidence: 95%

A Successful Outcome Despite Delayed Intervention for Cauda Equina Syndrome in a Young Patient with a Posterior Epidural Disc Extrusion

Mugge

Caras

Miller

et al. 2019

Cureus

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Epidural disc extrusion is extremely rare and may cause cauda equina syndrome. This is a surgical emergency and needs rapid decompression. Although cauda equina is commonly caused by disc herniation, this is an unusual presentation with epidural disc extrusion. We present a very rare case of Cauda Equina syndrome, resulting from an epidural disc extrusion at L3-L4 level. Patient care and progress notes were reviewed along with pre-, post-, and intra-operative radiological imaging. Here, a 19-year-old male with a past medical history of type I diabetes mellitus, fell asleep on a chair at home in an unusual position and was unable to walk on awakening. The patient developed progressive neurological deficits including bilateral foot drop along with bowel and bladder dysfunction. In addition, he experienced paresthesia and severe lower back pain unresponsive to steroids. Pre-operative magnetic resonance imaging (MRI) demonstrated a herniated disk epidurally with disc extrusion and mass effect and compression at the L3-L4 level, wrapping around the posterior aspect of the dura. A diagnosis of cauda equina syndrome was made and surgical decompression was performed. Using microsurgical technique and fluoroscopic guidance, a bilateral laminectomy of L3 was achieved with bilateral partial laminectomy of L4, with bilateral foraminotomy of L4. After removal of the lamina, a mass was immediately visualized in the posterior epidural space. Further dissection of the substance and following it posteriorly, identified the mass as a portion of the extruded disc. Post-operatively, the patient experienced rapid recovery. In conclusion, this case demonstrates that a disc extrusion can occur within the epidural space and can cause cauda equina syndrome. As this presentation is unusual, surgeons must be aware that they may encounter disc mass in unexpected locations, in a clinically delayed setting, long after the initial onset of symptoms.

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“…[ 1 , 4 , 6 , 10 , 16 , 18 ] In 2017, Thakur et al ., using the NISC (2005–2011) database involvling 4066 adults with CES, determined that surgery in ICES patients performed in <24 h. resulted in better outcomes with lower mortality rates, shorter lengths of stay, lesser hospital charges, and a reduced rate of unfavorable discharges versus surgery performed after 48 h [ Table 1 ]. [ 17 ] Hogan et al . (2019), based on a National Inpatient Sample Database of 20, 924 CES patients, additionally confirmed that early CES surgery (i.e.…”

Section: Surgery For Ices and Rces Syndromes: “The Sooner The Better”...mentioning

confidence: 99%

“…[ 10 ] The operations performed in most studies included decompressive laminectomies with occasional decompressions/fusions [ Table 1 ]. [ 3 , 7 , 10 , 12 , 13 , 15 , 17 , 18 ]…”

Section: Surgery For Ices and Rces Syndromes: “The Sooner The Better”...mentioning

confidence: 99%

“…[ 1 , 4 - 6 , 9 , 10 , 14 , 16 - 18 ] CES syndromes are divided into incomplete/partial CES (ICES) versus complete/retention/incontinence CES (RCES) syndromes based upon the respective lesser or greater severity of preoperative motor, sensory, and/or sphincteric deficits. [ 9 , 16 , 17 ] ICES/RCES syndromes were largely attributed to; acute disc herniations/stenosis, iatrogenic-surgical trauma, trauma/fractures, infections/abscesses, and other factors. [ 1 - 18 ] Early surgery, predominantly including laminectomy to multilevel decompressions with/ without fusions, increased the probability of better outcomes for both ICES and RCES populations.…”

Section: Introductionmentioning

confidence: 99%

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Review/Perspective: Operations for Cauda Equina Syndromes - “The Sooner the Better”

Epstein¹

2022

Surgical Neurology International

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Background: Although most studies recommended that early surgery for cauda equina syndromes (CES) be performed within <48 h., the largest and most comprehensive Nationwide Inpatient Sample Database (NISC) series, involving over 25,000 CES patients recommended that time be shortened to 0–<24 h. In short, CES surgery performed “the sooner the better,” was best. Methods: The 2 major variants of CES include; incomplete/partial ICES, and those with urinary retention/bowel incontinence (RCES). Those with ICES often exhibit varying combinations of motor weakness, sensory loss (i.e. including perineal numbness), and urinary dysfunction, while RCES patients typically exhibit more severe paraparesis, sensory loss including saddle anesthesia, and urinary/bowel incontinence. The pathology responsible for ICES/RCES syndromes may include; acute disc herniations/stenosis, trauma (i.e. including iatrogenic/ surgical hematomas etc.), infections, abscesses, and other pathology. Surgery for either ICES/RCES may include decompressions to multilevel laminectomies/fusions. Results: Following early surgery, most studies showed that ICES and RCES patients exhibited improvement in motor weakness and sensory loss. However, recovery of sphincter function was more variable, being poorer for RCES patients with preoperative urinary retention/bowel incontinence. Conclusions: Although early CES surgery was defined in most studies as <48 h., two large NISC series involving over 25, 000 CES patients showed that CES surgery performed within 0 -< 24 h resulted in the best outcomes.

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Early intervention in cauda equina syndrome associated with better outcomes: a myth or reality? Insights from the Nationwide Inpatient Sample database (2005–2011)

Cited by 32 publications

References 28 publications

Adolescent idiopathic scoliosis: risk factors for complications and the effect of hospital volume on outcomes

Adolescent idiopathic scoliosis: risk factors for complications and the effect of hospital volume on outcomes

A Successful Outcome Despite Delayed Intervention for Cauda Equina Syndrome in a Young Patient with a Posterior Epidural Disc Extrusion

Review/Perspective: Operations for Cauda Equina Syndromes - “The Sooner the Better”

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