Neurosurgery for Cauda Equina Syndrome 

Background

The prognosis for cauda equina syndrome (CES) improves if a definitive cause is identified and management is instituted early. Surgical treatment may be necessary for decompression or tumor removal, especially if the patient presents with acute onset of symptoms. Surgical decompression should be performed if the patient is medically stable and able to undergo the procedure.^{[1, 2, 3, 4]}

In acute compression of the conus medullaris or cauda equina, surgical decompression as soon as possible becomes mandatory. In a more chronic presentation with less severe symptoms, decompression could be performed when medically feasible and should be delayed to optimize the patient's medical condition; with this precaution, decompression is less likely to lead to irreversible neurological damage.

The timing of surgical decompression is controversial, with immediate, early, and late surgical decompression showing varying results. In acute compression, the dictum was to operate emergently within 6 hours for CES,^[5] but several authors have argued over the clarity of the data supporting this practice.^{[6, 1, 2, 4, 7]} Hussain et al reported no differences at a 16-month follow-up among patients who underwent surgery within 5 hours and those who underwent surgery within 24 hours.^[8]

One study reported significant differences in outcome when surgery was delayed for more than 24 hours after bladder paralysis.^[9] Thongtrangan et al studied trauma-induced cases of CES patients and recommend that surgery be performed within 48 hours of syndrome onset reported that the bladder function in, if expected to recover, would happen within 3 months.^[10]

Images depicting cauda equina syndrome can be seen below.

Go to Cauda Equina and Conus Medullaris Syndromes and Tumors of the Conus and Cauda Equina for complete information on these topics.

Frequency

In the United States, approximately 1-3% of patients who undergo spinal surgery for CES have either atraumatic or traumatic types of CES.^[6] CES has no predilection for any race or either sex. Although CES can occur at any age, it is most often seen in adults in whom the spinal canal may already be compromised and stenosed.

Overview

The role of surgery is to relieve pressure from the nerves in the cauda equina (CE) region and to remove the offending elements. Surgical treatment may include laminectomy and instrumentation/fusion for stabilization or discectomy. After spinal surgery, internal stabilization with fixation devices may be needed in the same operative setting or at a later date.

Routine preoperative care is recommended. The goal of preoperative care is to make sure that the patient gets to the operating room in the recommended time frame to maximize chances of a complete recovery.

The intraoperative use of somatosensory and motor-evoked potentials (SSEPs) may be helpful in monitoring the patient.

Routine postoperative care is necessary for all patients. The recovery time depends on the duration and the extent of symptoms of CES and a multitude of other factors, including the etiology.

Postoperative physical and occupational therapies are often beneficial to the patient’s progress. Some patients may require inpatient or outpatient rehabilitation; therefore, a physical medicine and rehabilitation consultation should be considered early in the course of management.

Follow-up

If therapy is delayed, potential problems include residual weakness, incontinence, impotence, and sensory abnormalities. These problems may persist even with prompt decompression. Follow-up depends on the needs of the patient and recovery potential.

Complications

Ever-present adverse events of any spinal surgery include paralysis, along with urinary bladder, bowel, and sexual dysfunction. The specific risks of surgical complications for widely varied procedures and equally varied etiologies are beyond the scope of this article.