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Feature Article

abstract

Full article available online at Healio.com/Orthopedics. Search: 20140124-18

Cauda equina syndrome (CES) is a rare but serious neurosurgical emergency that can

have devastating long-lasting neurologic consequences. Compression of the cauda

equina can result in paralysis of bowel and bladder function. Such compression has

been considered the only absolute indication for surgery in cases of lumbar disk dis-

ease. Therefore, it is extremely important that physicians be aware of the condition

so that a surgeon is consulted before neurological damage becomes permanent. This

article reports the results of delayed surgical decompression in cases of lumbar disk

herniation with CES.

The study group comprised 14 patients (11 men and 3 women) with a mean age of 48

years (range, 36-57 years). Clinical presentation was chronic low back pain, sciatica,

and impaired sphincter function. All patients had a fenestration at the affected level

and site, and the disk fragments were excised and the disk space cleared. The surgeries

were performed 1 to 3 months after onset of sphinctric disturbance. Postoperatively,

all patients were relieved of back and/or leg pain and showed sensory improvement.

Twelve patients regained full control of urination and defecation. Lower extremity

strength improved in 9 patients.

The classical presentation of CES is not obvious. Even if surgery is performed late due

to delayed presentation, significant improvement in neurologic and bladder function

can still be expected.

The authors are from the Orthopedic Department, Tanta University School of Medicine, Tanta, Egypt.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Tarek A. Aly, MD, PhD, Orthopedic Department, Tanta

University School of Medicine, 48th Sarwat St, Tanta 31111, Egypt (elphara3on@hotmail.com).

Received: May 30, 2013; Accepted: August 20, 2013; Posted: February 7, 2014.

doi: 10.3928/01477447-20140124-18

Efficacy of Delayed Decompression ofLumbar Disk Herniation Causing CaudaEquina SyndromeTAREKA. ALY, MD, PHD; MOHAMEDOSAMAABORAMADAN, MD

Figure:Anteroposterior (A) and lateral (B) radio-

graphs of a 35-year-old man with cauda equina

syndrome. Note straightening of the lumbar spine.

A B

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Feature Article

Cauda equina syndrome (CES)

is a rare but serious neurosur-

gical emergency that can have

devastating long-lasting neurologic con-

sequences. The majority of ruptured orsequestrated disk fragments migrate in

upward, downward, or lateral directions

owing to anatomic properties of the ante-

rior epidural space.1 Compression of the

cauda equina could result in paralysis of

bowel and bladder function.1Such com-

pression has been considered the only

absolute indication for surgery in cases of

lumbar disk disease.2Few reports of cau-

da equina compression owing to lumbar

disk prolapse have been published, and

the prognosis for the recovery of bowel

and bladder function postoperatively has

been uniformly gloomy,3-5 although the

recovery of motor function has generally

been considered likely. Sphincter paraly-

sis is a rare (2%) but potentially disastrous

complication of lumbar intervertebral disk

prolapse.6Patients usually present first in

general practice and then in general medi-

cal, surgical, or orthopedic or rheumatolo-

gy departments. Therefore, it is extremely

important that physicians be aware of the

condition so that a neurosurgeon can be

consulted before the neurological damage

becomes permanent. The urgency of the

diagnosis and treatment of lumbar disk

herniation or sequestration may be com-

pared with that for extradural hematoma

in head injury.4,5

This article reports the results of de-

layed surgical decompression in cases of

lumbar disk herniation with CES.

MATERIALSANDMETHODSThe study group comprised 14 patients

(11 men and 3 women) with a mean age of

48 years (range, 36-57 years). The clini-

cal presentation was chronic low back

pain with sciatica bilateral in 12 patients

and unilateral in 2 patients (Figure 1).

Impaired sphincter function had occurred

from 24 hours to 3 months preoperatively.

Complete loss of sphincter control, mean-

ing that catheterization was required to

treat urinary retention (providing objec-

tive evidence of a severe lesion), occurred

in 8 patients. Partial sphincter loss oc-

curred in 6 patients, where they were able

to urinate by bladder compression, eitherby breath holding or by manually com-

pressing the abdomen.

All but 2 patients had weakness in their

legs, varying from weak dorsiflexion and

eversion of 1 foot to bilateral weakness se-

vere enough to prevent walking. Reflexes

were absent at the knee and ankle in 9 pa-

tients.

All patients had a sensory loss in the

perineum. Eleven patients had sensory

loss in the skin of the buttocks and upper

posterior thighs (saddle area), but in 3

patients it was confined to the perineum

(ie, the depths of the natal cleft: pericoc-

cygeal, perianal, and posterior labial or

scrotal areas). Perineal sensory impair-

ment was total (anesthetic) in 2 patients,

dense (analgesic) in 7, and moderate (hy-

poalgesic and hypesthetic, but with dis-

crimination preserved) in 5 patients. In

10 male patients, erection and ejaculation

were affected.

Plain radiographs of the lumbar spine

were examined for spondylotic changes,

narrowing of the bony canal in the sag-

ittal plane, and disparity in the distance

between the superior facets and the ped-

icles. Magnetic resonance imaging (MRI)

was performed for all patients to demon-

strate any compression on the thecal sac

(Figures 2-3).

The results were rated as follows: ex-

cellent indicated a return to normal blad-

der function; good indicated a definite

improvement; and poor indicated no im-provement.7

RESULTS

The lesion was at the L4/5 level in

11 patients, at the lumbosacral level in

2, and at the L3/4 level in 1. All patients

had a fenestration at the affected level and

site, and the disk fragments were excised

and the disk space cleared. The surger-

ies were performed 1 to 3 months after

onset of sphinctric disturbance because

of late presentation of the patients to the

authors institution. Twelve patients re-

gained full control of urination and def-

ecation. In 2 others, sphincter recovery

was incomplete. They were able to urinate

by straining. Postoperatively, all patients

were relieved of their back and/or leg

pain, and all patients showed sensory im-

provement. Strength in the lower extremi-

ties improved in 9 patients within 1 to 4

months. Among 10 men in whom erection

and ejaculation were affected, 8 patients

completely recovered and 2 reported pain-

ful incomplete erections and uncontrolled

ejaculations.

The overall results were excellent in 8

(57%) patients, good in 4 (29%), and poorin 2 (14%).

DISCUSSION

Cauda equina syndrome is a term ap-

plied to the clinical picture of perineal

sensory loss with disorder of voluntary

control of both anal and urethral sphinc-

ters as well as sexual responsiveness.

Clinical signs accompanying CES may

differ in different patients, but tradition-

Figure 1:Anteroposterior (A) and lateral (B) ra-

diographs of a 35-year-old man with cauda equina

syndrome. Note straightening of the lumbar spine.

A B

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Feature Article

ally the syndrome is characterized by low

back pain; bilateral or unilateral sciatica;

saddle hypoesthesia or anesthesia; mo-

tor weakness of the lower extremities;

impairment of anal, bulbocavernosus,

medioplantar, or Achilles tendon reflexes

bilaterally; rectal and bladder sphinc-

ter dysfunction; and sexual impotence.8

However, most patients do not present

with all the characteristic features of CES.

The most frequent symptoms at initial di-

agnosis are acute low back pain with uni-

lateral or bilateral sciatica and unilateral

or bilateral muscle weakness of the lower

extremities. Perineal sensory loss is a sen-

sitive and relatively specific sign in the

diagnosis of CES.9,10

Cauda equina syndrome is a relatively

uncommon condition, with an incidence

of approximately 2% to 3% of all her-

niated lumbar disks.11,12

Cauda equinasyndrome occurs more commonly in

men, with onset usually in the fourth de-

cade,13 and is characterized by sciatica,

saddle (perianal) anesthesia, urinary re-

tention, and variable sensory and motor

deficits of the lower extremity.

The timing of the treatment of CES

is controversial. It is considered a surgi-

cal emergency. Early decompression has

been shown to improve functional recov-

ery.12,14-16 In Shapiros13 experience, all

patients recovered urinary or stool conti-

nence if they underwent surgery within 48

hours of developing symptoms, compared

with one-third of patients who underwent

surgery after 48 hours. However, blad-

der function may take years to recover;

therefore, long-term follow-up is indi-

cated. Gleave and Macfarlane12 showed

no significant difference in time to surgi-

cal decompression. Several studies have

demonstrated no correlation between the

time to surgical decompression and re-

covery of neurologic and bladder func-

tions.17-19 Using animal models of CES,

Sayegh et al20 found no differences in

neurologic outcomes with early vs de-

layed intervention. Kostiuk et al21 found

no correlation between neurologic recov-

ery and decompression delay over a range

of hours to weeks. In the current study,although all surgeries were performed late

(1-3 months after the onset of CES symp-

toms), most patients recovered. What

variable accounts for the fact that some

patients do well with delayed decompres-

sion? The variable proposed is the mag-

nitude (amount) of compression that the

contents of the thecal sac can withstand.

Delamarter et al22 showed that at a con-

stant pressure (75% constriction of cauda

diameter), the time to decompression did

not play a role in functional or histologic

outcome. This may be explained by recov-

ery being more dependent on the nature of

the prolapse than the speed at which thenerve roots are compressed.

CONCLUSION

The current study has limitations. The

number of cases was small, which reflects

the difficulty in evaluating a relatively in-

frequent emergency presentation. Further

study is required to assess the effect of

varying grades of urological deficit in

CES, determined by urodynamic studies,

on postoperative outcome.

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