Long-term core outcomes in cauda equina syndrome

Abstract

Aims Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires. Methods Between January 2005 and December 2019, 82 patients underwent surgical decompression for acute CES secondary to massive lumbar disc prolapse at our hospital. After review of their records, patients were included if they presented with the clinical and radiological features of CES, then classified as CES incomplete (CESI) or with painless urinary retention (CESR) in accordance with guidelines published by the British Association of Spinal Surgeons. Patients provided written consent and completed a series of questionnaires. Results In total, 61 of 82 patients returned a completed survey. Their mean age at presentation was 43 years (20 to 77; SD 12.7), and the mean duration of follow-up 58.2 months (11 to 182; SD 45.3). Autonomic dysfunction was frequent: 33% of patients reported bladder dysfunction, and 10% required a urinary catheter. There was a 38% and 53% incidence of bowel and sexual dysfunction, respectively: 47% of patients reported genital numbness. A total of 67% reported significant back pain: 44% required further investigation and 10% further intervention for the management of lower back pain. Quality of life was lower than expected when corrected for age and sex. Half the patients reported moderate or worse depression, and 40% of patients of working age could no longer work due to problems attributable to CES. Urinary and faecal incontinence, catheter use, sexual dysfunction, and genital numbness were significantly more common in patients with CESR. Conclusion This study reports the long-term outcome of patients with CES and is the first to use validated patient-reported outcome measures to assess the CES Core Outcome Set. Persistent severe back pain and on-going autonomic dysfunction were frequently reported at a mean follow-up of five years. Cite this article: Bone Joint J 2021;103-B(9):1464–1471.

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

“…Acute or sub-acute compressive CES is a surgical emergency. With the recognition of DLMs, much literature will have to be revised appropriately [960][961][962][963]. Chronic CES from iatrogenic LMF is very distressing to patients, particularly those moving in and out of bowel and bladder sphincter control with disease fluctuation, but is not a surgical emergency [963,964] unless there is colonic atonia and the patient is in danger of ruptured bowel, or a similar life threatening condition-in which case the condition is the emergency, not the cauda equina.…”

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

“…perineal numbness), and urinary dysfunction, while RCES patients more typically had paresis/paralysis, more severe sensory loss including saddle anesthesia, and urinary/bowel retention/incontinence. [ 3 , 8 , 13 ] Preoperative symptoms in Barker et al . 61 ICES/RCES patients with acute lumbar disc herniations exhibited; low back pain (67%), perineal numbness (47%), bladder (33% with 10% of these requiring a Foley), and bowel dysfunction (38%).…”

“…61 ICES/RCES patients with acute lumbar disc herniations exhibited; low back pain (67%), perineal numbness (47%), bladder (33% with 10% of these requiring a Foley), and bowel dysfunction (38%). [ 3 ] Postoperatively, Hazelwood et al . (2019) 46 ICES/RCES patients exhibited residual/long-term loss of physical (48% motor/sensory), bladder (76%), bowel (13%), and sexual function (39%), with the worst outcomes seen in RCES patients.…”

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

“…Surgery performed “the sooner the better” for patients with cauda equina syndromes (CES) was best [ Table 1 ]. [ 1 , 3 - 18 ] Early surgery for CES was typically defined as within <48 h. after the onset of symptoms/signs; however, the two largest Nationwide Inpatient Sample Database (NISC) series recommend that CES surgery be completed within 0–<24 h. to achieve the best outcomes [ Table 1 ]. [ 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.…”