Cauda Equina Syndrome—retention type (CESR): Outcome after delayed discectomy and decompression for lumbar disc herniation

Abstract

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