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. 

In This Article

Results

Patient Characteristics

One hundred forty patients were included in our study (Table 1). As summarized in Table 1, there were 73 females and 67 males (52.1/47.9%) with a median age of 46.8 years (range 18–86 yrs). The mean FU of patients was 15.5 months (SD 6.1). At presentation, lumbar magnetic resonance imaging diagnosed herniated discs for 114 (81.6%) patients and 26 (18.4%) were diagnosed with a computed tomography scan. The Pfirrmann classification for discopathies and the levels involved in herniated discs were distributed in Table 1.[19]

Clinical Presentation

So, 72 patients (51.5%) had CES-C and (48.5%, n = 68) had CES-I (Table 1). Fifty-six patients (40%) presented sudden symptoms. The median time between onset of symptoms and the diagnosis of CES was 4 days (SD 62.2). One hundred ten patients (79.6%) presented previous unilateral (81, 57.8%) or bilateral (29, 20.7%) radicular pain. The median time between the onset of radicular pain and diagnosis of CES was 28 days for root symptoms (SD: 124).

Eighty-four patients (60%) presented a bilateral (28, 20%) or unilateral 56 (40%) motor deficit, in which 52 (37.1%) were multiradicular. Sixty-two patients (42.8%) presented a sensitive deficit (grade 1–2): 25 (20%) were bilateral. Concerning sphincter symptoms, 99 (70.7%) patients presented urinary dysfunctions; mainly incontinence (39; 27.9%), low stream (45, 32.1%), or bladder retention (29, 20.7%). In regards to rectal dysfunction, 62 patients (44.3%) presented bowel dysfunction. Genital dysfunctions were distributed as follows in 90 patients: 64.2% presented saddle anesthesia and 21 (15.0%) had an associated sexual dysfunction.

Surgery

All patients underwent surgical disc herniation decompression. Fourteen patients (10%) developed surgical complications mostly caused by incidental durotomy (11, 7.8%), hematoma (1, 0.7%). One patient presented early recurrence (day-2). Mean length of stay (LOS) was 6.9 days (SD 4.8). A majority of patients benefited from postoperative physiotherapy (100, 71.4%). Eighty-seven patients (62.1%) were discharged from the hospital and 53 (37.8%) were admitted to a rehabilitation center.

Recovery

Three visits were organized: V1 (2 mo), V2 (6 mo), and V3 (1 yr) (Table 2). At the first FU visit (V1) patients showed a statistical improvement of CES deficits: 49 of 84 patients (58.3%) recovered from their motor deficits (P < 0.0001), and 30 of 62 (48.3%) from their sensitive deficits (P = 0.003). Regarding sphincter CES improvement, 50 of 99 (51.5%) patients impaired their urinary/rectal dysfunctions (P = 0.538). Only 31 patients went back to work and one patient alone presented recurrence.

At the last FU visit V3, (median of 15.5 mo), results showed new improvements of motor and sensitive deficits: 57 of 84 patients with CES motor symptoms (67.8%) recovered from their deficit (P < 0.0001) and 39 of 62 (62.9%) improved their sensitive deficit (P < 0.0001).

Concerning sphincter symptoms, 52 of 99 (52.5%) patients improved their urinary dysfunction; mainly urinary continence (39; 27.9%), low stream/dysuria (45, 32.1%), or bladder retention (29, 20.7%) P = 0.123.

In regards to the 62 patients (44.3%) who initially presented bowel dysfunction, at the last visit, 22 (35.5%) presented a very minor dysfunction (NBD 0–6), 11 (17.7%) from minor to moderate dysfunction (NBD 7–13), and 29 (46.7%) severe dysfunction (NBD > 14) (P = 0.09). For genital troubles, only 20 of 62 (32.2) had an amendment of saddle anesthesia. No data was collected for sexual dysfunction improvement.

Prognosis of Motor and Sensitive Recovery

We identified that age >60 years (P = 0.018), L3-L4 disc herniation (P = 0.003), preoperative radicular pain (P = 0.037), severity of motor deficit (0–2) (P < 0.0001), bilateral deficit presentation (P < 0.0001), LOS < 3 days (P = 0.0017), absence of postoperative physiotherapy (P = 0.036), and also rehabilitation reeducation (P < 0.0001) were successively associated with motor recovery prognosis (Table 3). Cox multivariate proportional hazard model identified that bilateral motor deficit [OR 3.9, IC95% (1.223–12.711), P = 0.017] and an initial deficit severity of 0 to 2 [OR 7.23, IC95% (1.234 –21.719), P = 0.001] as prognosis factors of poor motor recovery. In contrast, only short LOS < 3 were associated with better motor recovery [OR 0.193, IC95% (0.04–0.923), P = 0.039), independently to reeducation or physiotherapy. In multivariate analysis, we only determined initial motor deficit to independently represent a prognosis factor of poor sensitive recovery [OR 3.123, IC95% (0.834–10.71), P = 0.008].

Prognosis of Sphincter Recovery

Time of surgery did not demonstrate to be a prognosis factor for recovery (Table 4). We identified that initial herniated disc at L4-L5 level [OR 2.338, IC 95% (1.112–4.915), P = 0.044] and initial bowel dysfunction [OR 2.177, IC 95% (1.045–4.537), P = 0.007] were significantly associated with poor recovery. Whatever the deficit (motor, sensitive, or sphincterial), neither early decompression (<24 h), nor CES-C versus CES-I presented better recovery.

Prognosis of Returning-to-work

At the end of the median FU of 15.5 months, only 46 of 130 (35.8%) patients returned to work (Table 5). In univariate analysis, we identified that a L5-S1 herniated disc (P = 0.018), initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunction sequelae (P = 0.02), and long LOS (P = 0.02) were associated with the returning-to-work prognosis. Cox multivariate proportional hazard model identified that poor motor deficit recovery (motor sequelae) [OR 5.93, IC 95% (1.252–28.123), P = 0.025] as well as poor sphincter recovery [OR 2.484, IC 95% (0.992–6.220), P = 0.042] were prognosis factors of low outcomes in returning-to-work.

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