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Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life

Published online by Cambridge University Press:  21 May 2015

Jason W. Busse ,
Mohit Bhandari ,
Joseph B. Schnittker ,
Kesava Reddy  and
R. Brett Dunlop
Jason W. Busse
Affiliation:
Oncidium Health Group Inc., Burlington, Ont Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont
Mohit Bhandari*
Affiliation:
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont Department of Orthopaedics, McMaster University, Hamilton, Ont
Joseph B. Schnittker
Affiliation:
Division of Neurosurgery, McMaster University, Hamilton, Ont
Kesava Reddy
Affiliation:
Division of Neurosurgery, McMaster University, Hamilton, Ont
R. Brett Dunlop
Affiliation:
Department of Orthopaedics, McMaster University, Hamilton, Ont
*
Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main St. W, Hamilton ON L8N 3Z5; 905 525–9140 x2825, [email protected]

Abstract

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Objective:

Cauda equina syndrome (CES) is a feared complication of lumbar disc herniation. It is generally accepted that CES requires decompression within 6 hours of symptom onset, but this time goal is rarely met, and the relative benefit of delayed decompression on functional status and quality of life (QOL) remains unknown. The study objective was to describe the functional status and quality of life outcomes for patients who undergo delayed surgical decompression for CES.

Methods:

Patients with CES who underwent decompression of a herniated lumbar disc during a 10-year period were assessed at hospital discharge and at least 4 months after the procedure. Evaluation of functional outcomes was based on a previously validated scale and QOL outcomes on the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire.

Results:

During the study period, 1100 patients with herniated discs were identified, and 14 underwent surgical decompression for CES. All 14 had had symptoms for more than 38 hours before surgery. Ten patients were available for long-term follow-up. There was a strong correlation between long CES symptom duration and poor functional outcome: of 8 patients with symptoms for less than 10 days before decompression (range, 1.6–7.5 d), all had good functional outcomes. The 2 patients with more prolonged symptoms (10.6 and 14.2 d) had poor outcomes. SF-36 scores demonstrated declines in physical roles (p = 0.03), social function (p = 0.03) and increased pain (p = 0.003) compared with population norms. Correlation between SF-36 domain scores and CES symptom duration failed to achieve statistical significance, perhaps because of small sample size.

Conclusions:

Patients who undergo delayed decompression for CES have increased pain and impaired social and physical function. Longer delays correlate with worse functional outcomes. Beyond 24 hours, decompression delay may be associated with a poorer quality of life but, because of the rarity of CES, the sample size in this study was too small to provide definitive conclusions. Since no patients underwent surgery within 38.4 hours of symptoms, it is not possible to comment on the importance of emergent decompression in early presenters.

Keywords

cauda equina syndromeintervertebral disc herniationquality of life
Type
EM Advances • Progrès de la MU
Information
Canadian Journal of Emergency Medicine , Volume 3 , Issue 4 , October 2001 , pp. 285 - 291
Copyright
Copyright © Canadian Association of Emergency Physicians 2001

References

1.DeLamarter, RB, Sherman, JE, Carr, JB.Cauda equina syndrome: neurologic recovery following immediate, early or late decompression. Spine 1992;16:1022–9.Google Scholar
2.Sayegh, FE, Kapetanos, GA, Symeonides, PP, Anogiannakis, G, Madentzidis, M.Functional outcome after experimental cauda equina compression. J Bone Joint Surg [Br] 1997;79:670–4.Google Scholar
3.Kostiuk, JP, Harrington, I, Alexander, D, Rand, W, Evans, D.Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg [Am] 1986;68:386–91.Google Scholar
4.Ahn, UM, Buchowski, JM, Ahn, NU, Sieber, A, Kostuik, JP.Cauda equina syndrome secondary to lumbar disk herniation: a metaanalysis of surgical outcomes. Presented at the annual meeting of American Academy of Orthopaedic Surgeons, Anaheim, Calif., Feb. 4–8, 1999.Google Scholar
5.Lang, DA, Neil-Dwyer, G, Garfield, J.Outcome after complex neurosurgery: the caregiver’s burden is forgotten. J Neurosurg 1999;91:359–63.Google Scholar
6.Fitzpatrick, R.Surveys of patient satisfaction: I — Important general considerations. BMJ 1991;302:887–9.Google Scholar
7.Chang, HS, Makagawa, H, Mizuno, J.Lumbar herniated disc presenting with cauda equina syndrome. Long-term follow-up of four cases. Surg Neurol 2000;53:100–4.Google Scholar
8.Williamson, C.The challenge of lay partnership. BMJ 1999;319: 721–2.Google Scholar
9.Gerszten, PC.Outcomes research: a review. Neurosurg 1998;43:1146–56.Google Scholar
10.Ware, JE Jr, Sherbourne, CD.The MOS 36-item Short-Form Health Survey (SF-36): I. Conceptual framework and item selection. Med Care 1992;30:473–83.Google Scholar
11.Ware, JE Jr, Snow, KK, Kosinski, M, Gandek, B.SF-36 Health Survey: manual and interpretation guide. Boston: Nimrod Press; 1993.Google Scholar
12.Tandon, PN, Sankaran, B.Cauda equina syndrome due to lumbar disc prolapse. Indian J Orthop 1967;1:112–9.Google Scholar
13.Epstein, NE, Hood, DC.A comparison of surgeon’s assessment to patient’s self analysis (short form 36) after far lateral lumbar disc surgery. An outcome study. Spine 1997;22:2422–8.Google Scholar
14.Shapiro, S.Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery 1993;32:743–7.Google Scholar
15.Kantz, ME, Harris, WJ, Levitsky, K, Ware, JE, Davies, AR.Methods for assessing condition-specific and generic functional status outcomes after total knee replacement. Med Care 1992;30(5 Suppl):MS240–52.Google Scholar
16.Grevitt, M, Khazim, R, Webb, J, Mulholland, R, Shepperd, J.The short form-36 health survey questionnaire in spine surgery. J Bone Joint Surg [Br] 1997;79:48–52.Google Scholar
17.Kardaun, J.Acute complications in patients with surgical treatment of lumbar herniated discs. J Spine Disord 1990;3:30–8.Google Scholar
18.Choudhury, AR, Taylor, JC.Cauda equina syndrome in lumbar disc disease. Acta Orthop Scand 1980;51:493–9.Google Scholar
19.Parke, WW, Gammell, K, Rothman, RH.Arterial vascularization of the cauda equina. J Bone Joint Surg [Am] 1981;63:53–62.Google Scholar
20.Wippold, FJ 2nd, Smirniotopoulos, JG, Pilgram, TK.Lesions of the cauda equina: a clinical and pathology review from the Armed Forces Institute of Pathology. Clin Neurol Neurosurg 1997;99:229–34.Google Scholar
21.Jennett, WB.A study of 25 cases of compression of the cause equina by prolapsed intervertebral discs. J Neurol Neurosurg Psychiatry 1956;19:109–16.Google Scholar
22.Aho, A, Auranen, A, Pesonen, K.Analysis of cauda equina symptoms in patients with lumbar disc prolapse. Acta Chir Scand 1969;135:413–20.Google Scholar
23.Tay, ECK, Chacha, PB.Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina. J Bone Joint Surg [Br] 1979;61:43–6.Google Scholar
24.Bonaroti, EA, Welch, WC.Posterior epidural migration of an extruded lumbar disc fragment causing cauda equina syndrome. Spine 1998;23:378–81.Google Scholar
25.Murrey, DB, Hanley, EN.Surgery for lumbar disc herniation: What are the choices? J Musculoskel Med 1999;16:39–45.Google Scholar
26.Frymoyer, JW.Back pain and sciatica. N Engl J Med 1988;318: 291–300.Google Scholar
27.Coscia, M, Leipzig, T, Cooper, D.Acute cauda equina syndrome. diagnostic advantage of MRI. Spine 1994;19:475–8.Google Scholar
28.Gibson, JNA, Grant, IC, Waddell, G.Surgery for lumbar disc prolapse (Cochrane Review). In: The Cochrane Library, Issue 3, 1999. Oxford: Update Software.Google Scholar
29.Grane, P, Tullberg, T, Rydberg, J, Lindgren, L.Postoperative lumbar MR imaging with contrast enhancement. Comparisons between symptomatic and asymptomatic patients. Acta Radiologica 1996;37:366–72.Google Scholar
30.Shepard, R.Diagnosis and prognosis of cauda equina syndrome produced by protrusion of lumbar disc. BMJ 1959;2:1434–9.Google Scholar
31.McLaren, AC, Bailey, SI.Cauda equina syndrome: a complication of lumbar discectomy. Clin Orthop 1986;204:143–9.Google Scholar
32.O’Laoire, SA, Crockard, HA, Thomas, DG.Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disc prolapse. BMJ 1981;282:1852–4.Google Scholar
33.Floman, Y, Wiesel, SW, Rothman, RH.Cauda equina syndrome presenting as a herniated lumbar disk. Clin Orthop Rel Res 1980;147:235–7.Google Scholar
34.Nielsen, B, de Nully, M, Schmidt, K, Hansen, I.A urodynamic study of cauda equina syndrome due to lumbar disc herniation. Urol Int 1980;35:167–70.Google Scholar
35.Hellstrom, P, Kortelainen, P, Kontturi, M.Late urodynamic findings after surgery for cauda equina by prolapsed intervertebral disk. J Urol 1986;135:308–12.Google Scholar
36.Kerr, RS, Cadoux-Hudson, TA, Adams, CB.The value of accurate clinical assessment in the surgical management of the lumbar disc protrusion. J Neurol Neurosurg Psychiatry 1988;51:169–73.Google Scholar
37.Lafuente, DJ, Andrew, J, Joy, A.Sacral sparing with cauda equina compression from central lumbar intervertebral collapse. J Neurol Neurosurg Psychiatry 1985;48:579–81.Google Scholar
38.Robinson, R.Massive protrusions of lumbar discs. Br J Surg 1965;52:858–65.Google Scholar
39.Smith, S, Leibrock, L, Gelber, B, Pierson, E.Acute herniated nucleus pulposus with cauda equina compression syndrome following chemonucleolysis. J Neurosurg 1987;66:614–7.Google Scholar
40.Egger, M, Schneider, M, Smith, GD.Spurious precision? Metaanalysis of observational studies. BMJ 1998;316:140–4.Google Scholar
41.Thompson, SG, Pocock, SJ.Can meta-analyses be trusted? Lancet 1991;338:1127–30.Google Scholar
42.Junge, A, Dvorak, J, Ahrens, S.Predictors of bad and good outcomes of lumbar disc surgery: a prospective clinical study resulting in recommendations for screening to avoid bad outcomes. Spine 1995;20:460–8.Google Scholar
43.Junge, A, Frohlich, M, Ahrens, S, Hasenbring, M, Sandler, A, Grob, D, et al. Predictors of bad and good outcomes of lumbar disc surgery: a prospective clinical study with 2 years’ follow-up. Spine 1996;21:1064–5.Google Scholar
44.Bouchet, C, Guillemin, F, Briançon, S.Nonspecific effects in longitudinal studies: impact on quality of life measures. Clin Epidemiol 1996;49:15–20.Google Scholar
45.Camilleri-Brennan, J, Steele, RJC. Measurement of quality of life in surgery. J R Coll Surg Edinb 1999;44:252–9.Google Scholar
46.Wood-Dauphinee, S.Assessing quality of life in clinical research: From where have we come and where are we going? J Clin Epidemiol 1999;52:355–63.Google Scholar