|Year : 2022 | Volume
| Issue : 1 | Page : 112-119
Cauda Equina Syndrome—retention type (CESR): Outcome after delayed discectomy and decompression for lumbar disc herniation
Ujjwal Kanti Debnath, Sishir Kumar, Rishi Thakral, Tarun Chabra, Gourab Chatterjee
Department of Orthopaedics & Spine Surgery, Jagannath Gupta Institute of Medical Sciences & Hospital, Kolkata, West Bengal, India
|Date of Submission||21-Nov-2020|
|Date of Decision||01-Aug-2021|
|Date of Acceptance||06-Oct-2021|
|Date of Web Publication||02-Feb-2022|
Ujjwal Kanti Debnath
Department of Orthopaedics & Spine Surgery, Jagannath Gupta Institute of Medical Sciences & Hospital, Buita, Budge Budge, Kolkata 700137, West Bengal.
Source of Support: None, Conflict of Interest: None
Background: The objective of this study was to evaluate the functional outcome after lumbar discectomy in Cauda equina syndrome—retention type (CESR) patients with delayed presentation. Materials and Methods: Fourteen patients with CESR presenting after 48 h (i.e., 2–42 days) from the onset of symptoms were included in the study. Acute lumbar disc prolapse was the cause of CESR in all patients. A detailed history including age, sex, onset of back pain, bladder and bowel symptoms, neurological signs, level of lesion, timing of surgery, and neurologic recovery (resolution of pain, sensory and motor deficits, and urinary, rectal, and sexual dysfunction [SD]) were recorded and analyzed. Bladder dysfunction was assessed using the urinary symptom profile (USP) questionnaire. Bowel dysfunction was assessed using the neurogenic bowel dysfunction (NBD) questionnaire. SD in men was analyzed using the international index of erectile function (IIEF) questionnaire and Female SD was analyzed using the female sexual function index (FSFI) questionnaire. Physical and mental health was assessed by short-form 12 (SF-12). Results: 9M:5F with a mean age of 35 years (range 26–45 years) presented with back and leg pain, parasthesia in the limbs, and retention of urine. Nine patients had acute backache and five had chronic back pain. All patients were catheterized on admission. The disc herniation levels were L4/L5 (seven patients), L5/S1 (six patients), and one had L3/4. The mean time of onset of symptoms to presentation at the hospital was 9.7 days (range 2–42 days). Preoperative mean Oswestry disability index (ODI) was 67.4 (range 58–80), mean visual analog score (VAS) for back pain was 2.8 (range 0–7) and mean VAS for leg pain was 6.5 (range 5–9). Preoperatively, motor power was affected in 12 patients. At presentation, perianal sensation (PAS) was labeled as “decreased,” in 12 patients (85.7%), and “absent” in two patients (14.3%). Voluntary anal contraction (VAC) was reported as “weak” in 10 patients (71.5%) and “absent” in 4 patients (28.5%).At a mean follow-up of 30 months, five patients had complete and five patients had partial recovery of motor and sensory deficit. Complete restoration of bladder status was experienced in eight patients after a mean duration of 6 months following surgery (ranging from 3 to 10 months). Three patients had partial recovery of bladder function (stress or nocturnal incontinence or signs of post-voiding residual urine) after a mean duration of 10 months following surgery (range 7–15 months). The return of bowel functions was determined as “complete” in seven (50%), “partial” in five (35.7%) and “no recovery” in two patients (14.3%). All patients had varying grades of SD. The mean SD scores in the nine male patients were 36.1 ± 20.4. In the five female patients, the mean SD scores were 22.9 ± 6.2. The mean physical component summary (PCS) and mental component summary (MCS) scores were 44.7 ± 8.8 and 40.1 ± 10.7, respectively. The group mean was significantly lower (P < 0.0001) as compared to the population norm for age groups 25–45 years. Conclusion: Late presentations of patients with CESR had variable long-term outcomes following lumbar discectomy. The recovery of the bladder and sexual function probably is the worst affected after late decompression. Validated questionnaires provide the clinicians a guide to prognosticate.
Keywords: Cauda equina syndrome, late decompression, lumbar disc herniation, recovery of bladder and bowel function
|How to cite this article:|
Debnath UK, Kumar S, Thakral R, Chabra T, Chatterjee G. Cauda Equina Syndrome—retention type (CESR): Outcome after delayed discectomy and decompression for lumbar disc herniation. Indian Spine J 2022;5:112-9
|How to cite this URL:|
Debnath UK, Kumar S, Thakral R, Chabra T, Chatterjee G. Cauda Equina Syndrome—retention type (CESR): Outcome after delayed discectomy and decompression for lumbar disc herniation. Indian Spine J [serial online] 2022 [cited 2022 May 25];5:112-9. Available from: https://www.isjonline.com/text.asp?2022/5/1/112/337149
| Introduction|| |
Cauda equina syndrome (CES) due to prolapsed lumbar disc is relatively rare (3%). In developing countries due to delay in diagnosis and late presentation of patients there may be permanent neurological damage. CES is classified into CES suspicious (CESS), incomplete CES (CESI), and complete CES (or CES with true retention; CESR) types according to BASS (British Association of Spine Surgeons) criteria. The BASS classification is a safe system with prognostic benefits. In CESI, patients present with motor and sensory changes, including saddle anesthesia, but yet to develop full retention or incontinence of either bowel or bladder. In CESR, patients have already developed true retention. Secondary to loss of the visceral neurologic signal to the central nervous system, painless urinary retention, and eventually overflow incontinence, is experienced. Similarly, dysfunction of the bowel may be experienced.Most studies recommend urgent surgical decompression within 48–72 h of symptoms onset to reap the maximal benefits of surgery.,,,,
Problems arise in perceived delay in management and there are a variety of opinions regarding the optimum timing for surgery. Overall outcome was defined by resolution of pain, sensory and motor deficits, and urinary, rectal, and sexual dysfunction (SD).
| Materials and Methods|| |
A retrospective clinical study of 27 consecutive patients between 2011 and 2019 with complete CES caused by lumbar disc herniation was recorded. Institutional ethical committee approval was obtained for the study. Fourteen patients who had CESR secondary to lumbar disc herniation as confirmed by clinical and imaging studies were included in this study. One patient with CES was lost to follow-up after surgery. The rest 11 patients with CESI (44%) were excluded from the study.
All patients had low back pain and radicular pain before the appearance of neurological deficit, reduced muscle power and sensory disturbances specific to CES. All patients with CESR had urinary retention and incontinence. Representative preoperative magnetic resonance imaging (MRI) scans of two patients are shown in [Figure 1] and [Figure 2]. Time of presentation to hospital and time to surgical decompression was recorded. “Late” presentations were defined as patients presenting with clinical features of CESR presenting beyond 48 h.
|Figure 1: Proton density sagittal MRI scan showing L5/S1 large PIVD in 34-year-old man (case 7)|
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|Figure 2: Axial T2 MRI scan showing right L4/5 PIVD in 4-year-old woman (case 9)|
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Multiple variables were recorded and analyzed, with a focus on postoperative restoration of bladder and bowel function [Table 1] and [Table 2]. All underwent open discectomy at the affected lumbar segment. A wide laminectomy and extensive decompression with foraminotomies (as the accepted norm of surgical technique for CES) was performed routinely by the senior author.,,,
The bladder recovery was defined as “complete” or “partial”. Bladder function recovery was “complete” if the patient had no residual bladder symptoms and “partial” if the patient required to strain but did not require clean intermittent catheterization with a residual urine volume <100 mL. Those who required intermittent catheterization or had a residual volume >100 mL were considered to have “no” recovery. Bladder dysfunction was also assessed using the urinary symptom profile (USP) questionnaire with dysfunction defined by a score≥1. This allows the urinary symptoms to be classified into 3 domains, that is, stress incontinence, overactive bladder (OAB), and low stream. Increasing scores indicate worsening dysfunction. All patients were followed for a minimum period of 2 years.
The recovery of bowel function was rated as complete, partial, and no recovery. Bowel dysfunction was assessed using the neurogenic bowel dysfunction (NBD) questionnaire, which categorizes bowel dysfunction into “very minor” (score 0–6), “minor” (7–9), “moderate” (10–13), and “severe” (14+), and rates overall bowel satisfaction out of 10.
SD in men was analyzed using the international index of erectile function (IIEF) questionnaire and female SD was analyzed using the female sexual function index (FSFI) questionnaire., Physical component summary (PCS) and mental component summary (MCS) of the short-form 12 (SF-12) were answered by all patients, which was compared to the standard population norm for age group 25–45 years. An independent interview was conducted for the patients when they filled up the questionnaires regarding their employment status.
At the end of minimum of 2-year follow-up, the outcome was defined as “good,” “fair” and “poor.” A good outcome was defined as complete resolution of bladder dysfunction, complete recovery of motor, near-normal perianal anesthesia, and recovery of bowel bladder function. A “fair” outcome was defined as partial bladder or bowel recovery, partial motor or sensory function recovery, and persistence of perianal anesthesia. A “poor” outcome was defined as residual bladder compromise, significant anal sphincter dysfunction, poor fecal continence, residual motor function deficit, or persistence of perianal anesthesia. It is worthwhile mentioning that Dhatt et al. had arbitrarily divided their results into three groups as total recovery, near-total recovery, and partial recovery.
Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) software version 20.0 (IBM, Armonk, New York). Descriptive statistics were expressed in mean ± standard deviation (SD) or median (min–max) for continuous variables. The categorical variables were presented in number and percentage. Independent t test or paired t test was performed for continuous or ordinal variables. P Value was considered significant at 5% level.
| Results|| |
There were nine men and five women with a mean age of 35 years (range 26–45 years). The delay in presentation from the onset of disturbances in micturition (which was arbitrarily considered as a starting point of CES) ranged from 2 to 42 days (mean 10.4 days). From the time of presentation to surgical decompression it was 5–72 h.
MRI suggested L4–L5 level as the most frequent compression site (n = 7, 50%), followed by L5–S1 in six patients (42.8%) and L3–L4 in one patient (7.1%) [Table 1]. The average follow-up duration was 30 months (range, 24–48 months).
Oswestry disability index and visual analog score
Preoperative Oswestry disability index (ODI) was 67.4 (range 58–80), whereas at 2 years it was 16 (range 4–32) (P < 0.0001). The visual analog score (VAS) for back pain before surgery was 2.8 (range 0–7) but at final follow-up was 0.64 (range 0–2) (P < 0001) (t = –5.09). The mean change in VAS for back pain was 2.2 ± 1.5. The mean VAS for leg pain before surgery was 6.5 (range 5–9) and at final follow-up was 1.3 (range 0–3) (P < 0.0001) (t = –18.5). The mean change in VAS for leg pain was 5.3 ± 1.03 [Table 3].
Preoperatively, motor power in lower limbs was affected in 12 patients, 2 of them had bilateral involvement, whereas 10 had unilateral involvement of the affected myotomes. The MRC grade varied between Grade 1 to Grade 3 of the affected myotomes. At the final follow-up, the motor power in the unilateral affected limbs returned to normal (Grade 5) in five patients. Partial improvement of motor power was noted in the five patients with unilateral affection. The functional motor power was partially restored in one patient with bilateral involvement but the other did not improve.
Perianal sensation)/voluntary anal contraction
At presentation, perianal sensation (PAS) was labeled as “decreased,” in 12 patients (85.7%), and “absent” in two patients (14.3%). VAC was reported as “weak” in 10 patients (71.5%) and “absent” in four patients (28.5%) [Table 1]. No patient diagnosed with CESR had normal VAC.
Restoration of bladder status
Classification of bladder function outcome outlined by Gleave and Macfarlane was used for the study. Complete restoration of bladder status was experienced in eight patients after a mean duration of 6 months following surgery (ranging from 3 to 10 months). Three patients had partial recovery of bladder function (stress or nocturnal incontinence or signs of post-voiding residual urine) after a mean duration of 10 months following surgery (range 7–15 months). Two of these were able to void by self-intermittent catheterization, whereas one patient had some residual symptoms like urgency but was able to self-void with some difficulty. Three patients had continued to have either indwelling or intermittent catheterization of which two had a relatively longer duration of preoperative symptoms (11 and 42 days) and absent PAS. The patient reported mean total USP scores for the complete recovery group was 9.37 (±1.76) with breakdown mean scores of stress incontinence as 1.6 (±0.74), OAB 5.6 (±1.0), and low stream 2.0 (±0.9) [Table 4]. Overall, the bladder recovery pattern was determined as “complete” in eight (57.1%), “partial” in three patients (21.4%), and “no recovery” in three patients (21.5%).
Return of bowel function
The return of bowel functions was determined as “complete” in seven (50%), “partial” in five (35.7%) and “no recovery” in two patients (14.3%). The mean NBD scores in the complete recovery group were 6.4 (±2.3), partial recovery group was 12.2 (±1.15) and in the no recovery group was 29.0 (±1.4) [Table 4]. The complaints that were mentioned in the partial group were as follows: abnormal sensation of passing stool (n = 2); abnormal sensation of passing stool and incontinence (n = 2); incontinence (n = 1). In the “no recovery” group the complaints were manual evacuation of stool (n = 1); incontinence (n = 1).
SD was reported by all at the final follow-up. The mean SD scores in the nine male patients were 36.1 ± 20.4. The total scores revealed SD to be severe in three (33%) (mean score 11.3 ± 4.9), moderate in one (11%) (mean score 30 ± 0), and mild in five (56%) (mean score 52.2 ± 4.5) [Table 5]. Erectile dysfunction (mean score, 14.1 ± 8.1) was found to be mild in five, moderate in one, and severe in three patients.
|Table 5: Patient characteristics at final follow-up showing sexual dysfunction scores|
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In the five female patients, the mean SD scores were 22.9 ± 6.2. The total scores revealed SD to be severe in one (20%), moderate in two (40%), and mild in two (40%) patients [Table 5].
Physical and emotional wellbeing
The SF-12 is shown to have a statistically significant poorer physical function and mental wellbeing. The mean PCS and MCS scores were 44.7 ± 8.8 and 40.1 ± 10.7, respectively. The group mean was significantly lower (P < 0.0001) as compared to the population norm for age groups 25–45 years, that is, mean PCS of 52.2 ± 0.57, and mean MCS of 51.1 ± 0.19. The patients with severe bladder and bowel dysfunction were more disabled than others with much lower PCS and MCS scores.
Only five patients had returned to previous employment and three had resumed their respective employment in reduced capacity. Others had been unable to work. Residual symptoms were present in many patients with 50% (n = 7) reporting areas of sensory loss and leg weakness, including 42% (n = 6) requiring walking aids to mobilize. Intermittent back pain was a significant problem in 57%. Most patients underwent community-based physiotherapy at home. Bladder and bowel dysfunction has been a significant barrier for 57% of patients in their daily activities of living.
Final outcome analysis
The pattern of recovery was quite variable in these patients who presented late with CESR. Therefore, it was difficult to group the outcomes. Nevertheless, a general analysis was done to have an idea of overall outcome. In the eight patients who had complete bladder recovery, seven had bowel function recovery, motor function recovered completely in five patients and recovery of perianal anesthesia was complete or approximately 90% of normal in five patients.
3 out of 8 patients with complete bladder recovery were included in the “fair” group as they had other parameters in different stages of recovery. Three patients with partial recovery of bladder function had variable patterns of recovery of other parameters. Three patients with no bladder recovery were grouped as “poor” outcome.
Therefore, ’good’ outcome was observed in five (36%) patients, “fair” outcome was observed in six (43%) and “poor” outcome was observed in three (21%). Due to the variable improvements in SD, it was difficult grouping them with other parameters.
| Discussion|| |
CESR may present with myriad of symptoms of which disturbance of bladder and bowel function are devastating. It is a time-sensitive syndrome, requiring rapid and effective assessment, diagnosis and treatment if the best possible outcome for the patient is to be achieved. Surgery should be performed in optimal conditions and not just as soon as possible, regardless of time of the day. The late presentation of patients in developing nations delays the surgical procedure in CES patients. Eventually, they continue to evolve into CESR type with a more profound neurological deficit. The delay in presentation may be due to myriad of causes. They are poverty, ignorance, remote residence, unavailability of the skilled spinal surgeon, apprehension of the anticipated neural injury during spinal surgery and becoming permanently disabled. Alternative treatment in these late presenting patients can be expectant and supportive. It is known that 20% CES patients will have poor outcome that may require supportive treatment in the form of self-catheterization, managing SD, colostomy, urological and gynecological surgery, spinal injuries rehabilitation and psycho-social support.
The cohort of 14 patients in this series had presented late following the onset of symptoms (i.e., 2–42 days). The principal reasons for such late presentations were mainly ignorance, fear and being remotely placed without any acute emergency services. Although late presenting CESR does not uniformly lead to poor outcome, the patients were consented regarding possibilities of worse outcomes. Gardner et al. noted that 50%–70% of patients had CESR with poor prognosis. The duration from the time of symptom onset to surgery in CES has been extensively researched by several authors, and when feasible early surgery is recommended.,, There is no clear consensus regarding the urgency of decompression for patients with CESR.
Shephard studied a series of 13 patients with CES. Two had CESI; the other 11 had CESR with duration of onset from 5 days’ to 2 years’. The author concluded that the presence of either visceral or sensory involvement was more crucial than duration of CES. He advocated for early decompression but provided no clear analysis of patient outcomes.
The outcome was worse for CESR patients (acute-onset group) than for CESI patients (insidious-onset group). There was no correlation between time from onset to decompression and level of recovery.
In a series of 14 patients described by Shapiro (1993), 7 patients with CESR who underwent surgery after 48 h, only two had regained continence, 3 had permanent weakness requiring an assistive device for ambulation, and 2 had chronic sciatica. The severity of bladder dysfunction at the time of surgery was the dominant factor in the recovery. Many authors have suggested that the major determinant of outcome may be the severity or density of deficit.,, The urologic outcome varies according to time from symptom onset to decompression. The lumbar levels of L4–L5 were reported as the most commonly involved level., CESR is more likely to result in subsequent permanent damage to the nerves supplying bladder, bowel, and sexual function due to compression of the nerves in lumbo-sacral plexus.
McCarthy et al. concluded the following: symptoms duration before operation and speed of onset do not affect the outcome more than 2 years after surgery. They reported that PAS shows the least improvement. In our small series, the return of PAS was observed to be variable with no pattern of recovery but five patients who had complete recovery of bladder and bowel function also had good recovery of PAS. Micturition, defecation, and especially sexual function are topics of embarrassment and the discussion on these aspects are avoided by the patients., The mere presence of PAS (irrespective of the degree) was significantly related to improved bladder recovery. In their series, VAC was either absent or weak in all the patients. This was an objective finding; therefore, it is less likely to be a false positive. CES type was not assessed and it could have influence on the overall outcome. The presence of VAC abnormality had 100% sensitivity for establishing a diagnosis. Beculic et al. reported that 36%, 36%, and 28% of the patients had normal, partial retention, and complete retention of bladder function, respectively, at the final follow-up. In this series, PAS was completely absent in two patients and reduced in the rest but VAC was absent in three patients at presentation. At final follow-up there was no recovery of these patients with absent PAS or VAC at presentation. The rest of the patients had variable improvement of PAS or VAC. Aly et al. reported that 12 of 14 patients who presented within 1–3 months of bladder/bowel involvement with CES regained full sphincter control. In one study, the author suggests that that 9 of 12 (75%) patients regained full bladder control, whereas only two patients failed to regain control. Their series had 50% of patients with CESR, who had a relatively shorter duration of symptoms (mean of 5.5 months).
Bowel dysfunction is the symptom with the greatest variation of reported prevalence in the literature. An NBDS was used to objectively study the bowel dysfunction by Hazelwood et al. Previous studies reported between 40% and 60% bowel dysfunction.,,, In the current series, only two patients had continued to have severe bowel dysfunction requiring manual evacuation. Others with mild to moderate dysfunction did not have much disability which hinders in their daily activities of living.
Very few authors have addressed the issue of SD in CES owing to lumbar disc herniation. In a recent study, 18.1%, 21.2%, and 30.3% of men had severe, moderate, and mild SD, respectively. Normal function was seen in 30.4% cases. They also noted that 60% of female patients suffered from SD, and it correlated remarkably with the patient’s age. But they did not mention the time of presentation and delay in surgery in these patients. Also they did not mention the status of CES whether CESI or CESR types. Patients presenting with CESR had significantly worse long-term outcomes in low stream bladder, bowel and sexual function as compared to those with CESI. The study is the only one in literature which has compared CESI and CESR assessing bladder, bowel, sexual and physical function. They also found that 71% were able to return to full employment, roughly matching the data from previous studies regarding spinal surgery over a long-term follow-up. In our series, all patients had variable grades of SD in both males and females.
Physical function is rarely objectively assessed in CES patients, but previous research agrees that the majority of patients score lower than the population average. McCarthy et al. assessed physical function using the Short-Form 36 questionnaire, a longer questionnaire from which the SF-12 was adapted and found CES patients to have significantly reduced function in the “Physical” and “Role Physical” domains. They are of the opinion that patients who had CES do not return to normal status. In this series, patients with profound bladder and bowel dysfunction had low scores in both physical and mental function domains of SF12. These few patients who did not regain control of bladder or bowel dysfunction had continued to remain dissatisfied with their performance in day-to-day life and reluctant to engage in employment.
Previous literature suggests between 28% and 57% had back pain at final follow-up which considerably disables the patients from daily activities., More than 50% patients in this series had complaints of back pain which was disabling at times. The patients have accepted this as a part of their lives and take analgesic medication when required.
Rydevik et al. found that there was a decrease in the functional recovery once a certain threshold pressure was surpassed, which may provide insight to the different recovery patterns seen clinically. Patients in our cohort could still be recovering and would be observed at different stages of recovery. These CESR patients requires long-term follow-up with measures such as intermittent self-catheterization and drug therapy, while expecting slow but steady recovery of bladder and sphincter function. We continue to follow up our patients monitoring various parameters expecting recovery.
The limitations of this study are (1) a small retrospective cohort of patients, (2) preoperative sexual history was not obtained, and (3) low number of patients did not allow for statistical analysis
| Conclusion|| |
Late presentations of patients with CESR had variable long-term outcomes in bladder, bowel and sexual function, as well as poor physical functioning and emotional wellbeing following lumbar discectomy. The recovery of the bladder and sexual function probably is the worst affected by late decompression. The validated questionnaires provide us a guide for outcomes of patients in a developing nation which will enable the clinicians to prognosticate.
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Conflicts of interest
There are no conflicts of interest.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]