Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome

Abstract

A prospective longitudinal inception cohort study of 33 patients undergoing surgery for cauda equina syndrome (CES) due to a herniated lumbar disc. To determine what factors influence spine and urinary outcome measures at 3 months and 1 year in CES specifically with regard to the timing of onset of symptoms and the timing of surgical decompression. CES consists of signs and symptoms caused by compression of lumbar and sacral nerve roots. Controversy exists regarding the relative importance of timing of surgery as a prognostic factor influencing outcome. Post-operative outcome was assessed at 3 months and 1 year using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores for leg and back pain and an incontinence questionnaire. Statistical analysis was used to determine the association between pre-operative variables and these post-operative outcomes with a specific emphasis on the timing of surgery. Surgery was performed on 12 (36%) patients within 48 h of the onset of symptoms including seven patients (21%) who underwent surgery within 24 h. Follow up was achieved in 27 (82%) and 25 (76%) patients at 3 and 12 months, respectively. There was no statistically significant difference in outcome between three groups of patients with respect to length of time from symptom onset to surgery- <24, 24-48 and >48 h. A significantly better outcome was found in patients who were continent of urine at presentation compared with those who were incontinent. The duration of symptoms prior to surgery does not appear to influence the outcome. This finding has significant implications for the medico-legal sequelae of this condition. The data suggests that the severity of bladder dysfunction at the time of surgery is the dominant factor in recovery of bladder function.

Fig. 1

Time from onset of symptoms to referral. Number of patients in each 24 h interval from onset of symptoms to time of referral

Fig. 2

Time from onset of symptoms to surgery. Number of patients in each 24 h interval from onset of symptoms to time of surgery

Fig. 3

Time from referral to surgery. Number of patients in each 24 h interval from time of referral to time of surgery

Fig. 4

Change in visual analogue score for back pain between follow ups. Difference in scores between early and late follow up for each patient plotted in ascending order

Fig. 5

Change in visual analogue score for leg pain between follow ups. Difference in scores between early and late follow up for each patient plotted in ascending order

Fig. 6

Change in oswestry disability index between follow ups. Difference in scores between early and late follow up for each patient plotted in ascending order