Cauda Equina Syndrome: Poor Recovery Prognosis Despite Early Treatment

Alexia Planty-Bonjour, MD; Gaelle Kerdiles, MD; Patrick François, MD, PhD; Christophe Destrieux, MD, PhD; Stephane Velut, MD, PhD; Ilyess Zemmoura, MD, PhD; Ann-Rose Cook, MD; Louis-Marie Terrier, MD; Aymeric Amelot, MD, PhD

Disclosures

Spine. 2022;47(2):105-113.

Materials and Methods

Ethics Statement

The protocol can be found in the reference methodology MR003 chapter adopted by the CNIL to which the University Hospitals of Tours conform.

Study Population

A prospective database of 140 consecutive patients operated for CES between January 2010 and 2019 was generated from the Neurosurgery Department. All patients underwent diagnostic and preoperative imaging before the extraction of the herniated lumbar disc responsible for the CES.

Clinical Symptom Evaluation

Motor deficits were graded on a scale of 0 to 5 according to the Medical Research Council scale for muscle strength.^[16] Sensitive deficits were also evaluated according to the Medical Research Council scale, with "0" representing disappearance, "1" altered, and "2" normal sensitivity.^[16] Bowel dysfunctions were evaluated during the FU with the neurogenic bowel dysfunction (NBD) score^[17] and bladder dysfunctions were defined by the Urinary symptoms Profile.^[18] The genital dysfunctions were collected at clinical examination: saddle anesthesia and interrogation about sexual dysfunction (erectile dysfunction or vaginal dryness).

Statistical Analyses

All tests were two-sided; P values < 0.05 were considered statistically significant. Univariate and multivariate Cox proportional hazard regression models were conducted using SPSS software, version 22.0 (SPSS, Chicago, IL). Establishment and verification of nomograms were implemented using the open source software R-version 3.2.5 with rms packages (Design, Vienna, Austria). Data are presented as the mean/median ± standard deviation. The distribution of categorical variables was described with frequencies and percentages, whereas continuous and normally distributed variables were described with means and standard deviations (SD). In the univariate analysis, categorical variables were assessed using Pearson Chi-square or Fisher exact test. The multivariate analysis was conducted separately for each diagnosis and the Cox proportional hazards model was used to estimate hazard ratios and 95% confidence intervals (CIs). The output was expressed as odds ratios and their bootstrapped 95% CIs. The Kaplan–Meier method was used to estimate the metastases free survival? For descriptive and inferential analyses, boot-strapping with replacement (iterations = 1000) was performed to attain variance estimates at the 95% CI.

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Table 1. Patient' Clinical, Imaging, and Postoperative Characteristics
Characteristics (140 Patients)	Value N (%) or [SD]
Age (yrs)	46.8 [14.5]
Gender
Male	67 (47.9)
Female	73 (52.1)
Follow-up (mo)	15.5
Medical history
Spine medical history	44 (31.4)
Spine surgery history	24 (17.1)
Obesity	30 (21.4)
Cancer	4 (2.9)
Cardiovascular history	23 (16.4)
Depression	10 (7.1)
Diabetes	2 (1.4)
Neurological history	7 (5)
Imaging
Pfirrmann classification
I	11 (7.8)
II	14 (10)
III	14 (10)
IV	60 (52.6)
V	15 (10.7)
Herniated disc location
L3-L4	21 (15)
L4-L5	52 (37.1)
L5-S1	67 (47.8)
Symptoms presentation
Onset
Sudden	56 (40)
Progressive	84 (60)
Evolution time (d)
Root symptoms	28 [124]
Cauda equina symptoms	4 [62.2]
Clinical examination
Radiculalgia
None	30 (21.4)
Bilateral	29 (20.7)
Unilateral	81 (57.8)
Motor deficit
None	56 (40)
Bilateral	28 (20)
Unilateral	56 (40)
Deficit score
0–2	17 (15%)
3	12 (10%)
4–5	84 (74%)
Sensitive deficit
None	78 (55.7)
Bilateral	25 (20)
Unilateral	37 (26.4)
Urinary dysfunction
Incontinence	39 (27.9)
Low stream	45 (32.1)
Bladder retention	29 (20.7)
Bowel dysfunction	62 (44.3)
Saddle anesthesia	90 (64.2)
CES complete/incomplete	72 (51.5)/68 (48.5)
Postoperative period
Surgery complication	14 (10%)
Hematoma	1 (0.7%)
Incidental durotomy	11 (7.8%)
Failure	2 (1.5%)
Stay duration (d)	6.9 [4.8]
Kinesitherapy	100 (71.4)
Exit location
Home	87 (62.1%)
Rehabilitation	53 (37.8%)

Table 2. Functional Recovery at the First and Last Follow-Up Visit
	Value N (%) or [SD]	P Value
Median time 1st FU (mo)	2.46 [1.1]
Motor deficit	49/84 (58.3)	<0.0001
Sensitive deficit	30/62 (48.3)	0.003
Genital and sphincter deficit	50/99 (51.5)	0.538
Back to work	31/130 (23.8)	–
Recurrences	1 (0.7)	–
Median time last FU (mo)	15.5 [16.2]
Motor deficit	57/84 (67.8)	<0.0001
Sensitive deficit	39/62 (62.9)	<0.0001
Genital and sphincter deficit	52/99 (52.5)	0.551
Back to work	46/130 (35.8)	–

Table 3. Univariate ( P Value Was Calculated by the Log-Rank Test) and Multivariate ( P Value Was Calculated by Cox Regression) Analysis for Prognostic of Motor Function Recovery
	Univariate Analysis (P)	Multivariate Analysis (P)	OR (CI 95%)
Age (yrs)
< 40 yrs	0.645
[40–60] yrs	0.119
> 60 yrs	0.018	0.132	2.368 [1.102–6.639]
Gender	0.673
Medical history
Spine medical history	0.165
Spine surgery history	0.356
Obesity	1.00
Herniated disc location
L3-L4	0.003	0.435	4.234 [2.009–8.511]
L4-L5	1.00
L5-S1	0.204
Symptoms presentation
Onset (sudden/progressive)	0.385
CES evolution time
< 24 h	0.481
[1–3] d	0.284
[3–7] d	0.493
>7 d	0.439
Clinical examination
Radiculalgia	0.037	0.239	1.923 [0,578–2.894]
Motor deficit
Bilateral	<0.0001	0.022	3,943 [1,223–12,711]
Deficit level
0–2	<0.0001	0.001	7,23 [1,234 – 21.719]
Sensitive deficit	0.282
Genital and sphincters symptoms	1.00
CES complete/incomplete	0.367
Postoperative period
Surgery complication
Incidental durotomy	1.00
LOS > 3 d	<0.0001	0.039	0.193 [0.040–0.923]
No physiotherapy	0.036	0.345
Rehabilitation	<0.0001	0.145

Statistically significant data are in bold.

Table 4. Univariate ( P Value Was Calculated by the Log-Rank Test) and Multivariate ( P Value Was Calculated by Cox Regression) Analysis for Prognostic of Genito-Urinary Function Recovery
	Univariate Analysis (P)	Multivariate Analysis (P)	OR (CI 95%)
Age (yrs)
< 40 yrs	0.08
[40–60] yrs	0.360
> 60 yrs	0.831
Gender	0.217
Medical history
Spine medical history	0.338
Spine surgery history	0.813
Obesity	0.822
Herniated disc location
L3-L4	1.00
L4-L5	0.044	0.025	2.338 [1.112–4.915]
L5-S1	0.372
Symptoms presentation
Onset (sudden/progressive)	0.585
CES evolution time
< 24 h	0.559
[1–3] d	0.472
[3–7] d	1.00
>7 d	0.525
Clinical examination
Motor deficit	0.716
Sensitive deficit	0.715
Radiculalgia	0.394
Cauda equina syndrome
Bowel dysfunction	0.007	0.038	2.177 [1.045–4.537]
Dysuria/low stream	0.912
Urinary incontinence	0.550
Bladder retention	0.095
Saddle anesthesia	0.133
CES complete/incomplete	0.639
Postoperative period
LOS > 3 d	0.348
No Kinesitherapy	0.9420
Rehabilitation	0.675

Statistically significant data are in bold.

Table 5. Univariate ( P Value Was Calculated by the KLog-Rank Test) and Multivariate ( P Value Was Calculated by Cox Regression) Analysis for Prognosis of Back-to-Work
	Univariate Analysis (P)	Multivariate Analysis (P)	OR (CI 95%)
Age
< 40 yrs	0.243
[40–60] yrs	0.118
> 60 yrs	–
Gender	1.00
Medical history
Spine medical history	0.172
Spine surgery history	0.325
Obesity	1.00
Herniated disc location
L3-L4	0.472
L4-L5	0.138
L5-S1	0.018	0.900	0.732 [0.356–0.977]
Symptoms presentation
Onset (sudden/progressive)	1.00
CES evolution time
< 24 h	0.236
[1–3] d	0.134
[3–7] d	0.826
Postoperative period
LOS > 3 d	0.023	0.399	3.933 [1.110–9.877]
No kinesitherapy	0.203
Rehabilitation	0.024	0.760	0.483 [0.525–1.193]
Final sequelae
Motor	0.001	0.025	5.933 [1.252–28.123]
Sensitive	1.00
Genital and sphincters	0.02	0.042	2.484 [0.992–6.220]

Statistically significant data are in bold.

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Cauda Equina Syndrome: Poor Recovery Prognosis Despite Early Treatment

Materials and Methods

Ethics Statement

Study Population

Clinical Symptom Evaluation

Statistical Analyses

Tables

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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