SPINE Volume 25, Number 12, pp 15151522 2000, Lippincott Williams & Wilkins, Inc.

Cauda Equina Syndrome Secondary to Lumbar Disc Herniation

A Meta-Analysis of Surgical Outcomes
Uri Michael Ahn, MD,* Nicholas U. Ahn, MD,* Jacob M. Buchowski, MS,* Elizabeth S. Garrett, PhD, Ann N. Sieber, RN, MSN,* and John P. Kostuik, MD*
Cauda equina syndrome (CES) is a severe neurologic disorder that can result from lumbar disc herniation with excessive compression on the cauda equina.23,45,50 More than 95% of uncomplicated herniated lumbar discs can be treated conservatively initially, with surgery reserved for patients who experience worsening of neurologic symptoms or failure to clinically improve after an appropriate conservative trial. In contrast, CES is a serious complication of lumbar disc herniation that requires an acute surgical decompression.23,50,93 Its clinical features can include severe low back pain, bilateral or unilateral sciatica, saddle anesthesia, motor weakness, sensory deficit, and urinary incontinence. It may progress to paraplegia and/or permanent incontinence.2,57,59,87,93,98,106 It is thought to be the primary absolute indication for the acute surgical treatment of lumbar disc herniation.1,50,92,93,95 Most investigators have recommended emergent surgical decompression for CES; however, results in certain studies have been cited to indicate that delayed surgery may also provide satisfactory outcomes.50 Kostuik et al50 reported clinical improvement in patients with CES who underwent decompression several days after onset. In this retrospective review, no statistical evaluation was performed to compare the degree of improvement of the patients with CES who underwent decompression earlier with improvement in those operated on later. Other investigators have made conclusions based on limited numbers of patients. Jennett45 stated anecdotally that the decompression of CES provided better bladder than bowel recovery. Dinning and Schaeffer23 thought that abatement of sciatic pain in CES heralded a worse prognosis. The compression required to eliminate pain conduction was thought to be greater than that required to cause the pain itself.23 Several reports have stated that after CES decompression sensory recovery is worse than motor recovery.23,45,69 The observation of OConnell69 that the sensory lesion with CES is proximal to the posterior root ganglion has been used to explain worsened postoperative sensory outcomes. The common problem in the literature is a limited number of patients studied because of the rarity of this disorder. This has resulted in studies that provide limited power because of an inability to provide statistical signicance.18,23,39,50,102 The purpose of the current study was to increase the statistical power of past studies in the English literature
1515

Study Design. A meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation. Objectives. To determine the relationship between time to decompression after onset of cauda equina syndrome and clinical outcome, and to identify preoperative variables that were associated with outcomes. Summary of Background Data. The timing of surgical decompression for cauda equina syndrome is controversial. Although most surgeons recommend emergent decompression, results in certain studies show that delayed surgery may provide a satisfactory outcome. Methods. A meta-analysis was performed to determine the correlation between timing of decompression and clinical outcome. One hundred four citations were reviewed, and 42 met the inclusion criteria. Preoperative and postoperative data were recorded. Length of time to surgery was broken down into ve groups: less than 24 hours, 24 48 hours, 210 days, 11 days to 1 month, and more than 1 month. Logistic regression was used to determine the association between preoperative variables and postoperative outcomes. Results. Outcomes were analyzed in 322 patients. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No signicant improvement in surgical outcome was identied with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24 48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Signicant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms. Conclusions. There was a signicant advantage to treating patients within 48 hours versus more than 48 hours after the onset of cauda equina syndrome. A signicant improvement in sensory and motor decits as well as urinary and rectal function occurred in patientswho underwent decompression within 48 hours versus after 48 hours. [Key words: cauda equina syndrome, lumbar disc herniation, surgical outcome] Spine 2000;25: 15151522

From the Departments of *Orthopaedic Surgery and Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Acknowledgment date: August 25, 1999. Acceptance date: November 1, 1999. Device status category: 1. Conict of interest category: 12.

1516 Spine Volume 25 Number 12 2000

Table 1. Preoperative Variables

Age Gender Laborer occupation History of previous spine surgery History of chronic low back pain Duration of chronic low back pain prior to CES History of trauma with onset of CES Sudden onset of CES Presence of sciatica with CES Preoperative weakness in lower extremities Preoperative sensory decit Preoperative loss of reexes Preoperative rectal dysfunction Length of time to surgery from onset of CES
CES cauda equina syndrome.

of CES caused by herniated lumbar disc by combining individual patient pools into a single meta-analysis. Specic preoperative variables were dened to identify those that were signicantly associated with improved or worsened postoperative outcomes. In addition, an effort was made determine the correlation between time to decompression after the onset of CES and clinical outcomes after surgery. Materials and Methods
A MEDLINE search was performed of CES caused by herniated lumbar disc from January 1966 through May 1999, and these articles were obtained. Additional earlier citations were obtained from the bibliographies of these works. One hundred four articles were obtained. Studies were considered eligible for the meta-analysis if they involved a clinical study of human patients with CES. Animal studies were immediately disqualied. Earlier articles were primarily case reports; however, more recent larger series were identied. In all included studies, CES was caused by a herniated lumbar disc. Articles with CES caused by spinal stenosis, tumor, hematoma, fracture, infection, or ankylosing spondylitis were not included. Patients in the current study drawn from eligible articles had all been treated with surgical decompression. Patients who refused surgery or were treated conservatively were not included. Preoperative and postoperative variables were dened by the authors and listed in Tables 1 and 2. Each patient from each study had to provide at least one pre- and one postoperative variable to be included in this study. All other patients were excluded. Forty-two articles met the criteria for inclusion in this study (see Appendix 2). Pre- and postoperative information was recorded on a data sheet. A collection of patients was included only if the pre- and postoperative variables of each patient were known. If preoperative variables differed in a col-

lection of patients and could not be matched with individual postoperative outcomes, the group of patients as a whole was excluded. The initial analysis consisted of regressing postoperative outcomes on the preoperative variables. Time to surgery was excluded from this part of the analysis (discussed later). A multivariate logistic regression analysis was attempted to control for confounding, but this was not possible, because the majority of patients had only a few of the preoperative and postoperative variables that were reported. Therefore, univariate logistic regression analyses were used to compare each binomial postoperative outcome with each preoperative variable. Coefcients and odds ratios (ORs) were determined comparing postoperative outcomes in patients with and without a specic preoperative variable. Signicance for each OR was determined. These data are summarized in Table 3 (parts I and II). In some regressions, a zero-cells situation was encountered with an OR of zero or innity. In these instances a Corneld approximation was used to determine an upper or lower limit to the 95% condence interval (CI) and a P value for signicance was calculated. If the 95% CI was found to be 0 innity, then the regression was excluded because of insufcient data. Analysis of time to surgery was performed separately in the following manner: Five groups were constructed for the time interval between the onset of CES and surgical decompression: less than 24 hours, 24 48 hours, 210 days, 11 days to 1 month, and more than 1 month. Time to surgery was stratied in this manner, because it provided a sufcient number of individuals in each group, and because it was of interest to determine whether a difference in postoperative outcomes would be present among the groups undergoing surgery less than 24 hours, between 24 and 48 hours, and more than 48 hours after onset of symptoms. The time of onset of cauda equina syndrome was explicitly stated in some articles. When it was not stated, it was inferred to be the time when the rectal or urinary (visceral) disorders began. These disorders varied greatly and included altered urethral sensation, loss of desire to void, poor stream, feeling of retention, micturition by straining, perirectal numbness, and loss of rectal control. Resolution of sensory and motor decits was difcult to quantify in some instances. In this study, resolution was characterized by a full resolution of the preoperative decit. A partial improvement in decits was recorded as a failure to resolve. A logistic regression analysis was performed for each postoperative outcome comparing these different covariate groups. Coefcients were estimated, and linear combinations of the differences between coefcients in each pair of covariate groups were used to calculate ORs comparing postoperative outcomes between covariate groups. Signicance was determined by the P value for each linear combination. The results are shown in Table 3. In the multivariate logistic regression analysis for the postoperative outcome resolution of sexual dysfunction, all coefcients could not be generated because of insufcient data and zero cells; thus, some of the ORs for this variable were excluded.

Table 2. Postoperative Variables

Resolution Resolution Resolution Resolution Resolution Resolution of of of of of of pain sensory decit motor decit urinary incontinence sexual dysfunction rectal dysfunction

Results Three hundred twenty-two patients (58% were male; mean age of 42.3 11.8 years, range, 20 69 years). Sixty-nine percent of the patients had a sudden onset of CES. Eighty-two percent had chronic low back pain for

Meta-Analysis of Cauda Equina Syndrome Ahn et al 1517

Table 3. Logistic Regression of Postoperative Outcomes on Preoperative Variables. Part I

Previous Surgery Resolution of pain OR 0.73 P 0.76 (0.095.6) N 21 OR 0.9 P 0.92 (0.117.0) N 21 OR 0.75 P 0.83 (0.0610.0) N 19 OR 0.39 P 0.26 (0.081.96) N 34 N 6 Sudden Onset OR 0.0 P .054 (0.03.4) N 33 OR 0.6 P 0.55 (0.113.3) N 36 OR 0.67 P 0.76 (0.058.5) N 24 OR 0.74 P 0.74 (0.134.3) N 47 N 6 Chronic Low Back Pain OR 4.3 P 0.32 (0.2479.6) N 34 OR 0.79 P 0.81 (0.115.5) N 34 OR 0.23 P 0.24 (0.022.6) N 28 OR 0.09 P 0.02 (0.010.68) N 98 OR 2.1 P 0.61 (0.1237.7) N 30 OR 0.04 P 0.01 (0.0030.5) N 21 Duration of Chronic sx OR 0.99 P .028 (0.981.0) N 40 OR 0.98 P 0.08 (0.961.0) N 41 OR 0.99 P 0.79 (0.981.01) N 32 OR 0.99 P 0.07 (0.981.0) N 49 OR 0.99 P 0.60 (0.961.02) N6 OR 1.01 P 0.31 (0.981.04) N8 Presence of Sciatica OR 0.0 P 1.0 (0.04.66) N 63 OR 0.0 P 0.55 (0.03.2) N 73 OR 0.0 P 0.46 (0.04.2) N 50 OR 0.0 P 0.07 (0.01.02) N 126 N 6 History of Trauma OR 0.0 P 0.49 (0.02.4) N 27 OR 0.39 P 0.26 (0.081.9) N 34 OR 0.8 P 0.81 (0.134.7) N 22 OR 0.14 P 0.08 (0.021.3) N 43 N 7 Age OR 0.77 P 0.30 (0.471.26) N 70 OR 1.0 P 0.97 (0.701.45) N 100 OR 1.27 P 0.36 (0.752.17) N 53 OR 0.93 P 0.63 (0.671.27) N 140 OR 0.39 P 0.03 (0.170.92) N 29 OR 0.50 P 0.1 (0.221.14) N 39 Gender OR 0.29 P 0.13 (0.061.5) N 66 OR 1.4 P 0.47 (0.603.04) N 98 OR 1.5 P 0.52 (0.474.5) N 53 OR 0.65 P 0.28 (0.301.4) N 139 OR 0.32 P 0.34 (0.033.3) N 30 OR 0.54 P 0.36 (0.142.1) N 39 Work as Laborer N 11

Resolution of sensory decit

OR P 1.0 (0.22) N 16 OR 2.5 P 0.58 (0.9962.6) N9 OR 0.66 P 0.79 (0.0312.9) N 17 N 3

Resolution of motor decit

Resolution of urinary decit

Resolution of sexual dysfunction

Resolution of rectal dysfunction

OR 0.33 P 0.55 (0.0111.9) N6

OR 1.0 P 1.0 (0.0713.9) N 18

OR 0.0 P 0.18 (0.01.16) N 11

OR P 0.54 (0.23) N 19

OR 0.0 P 0.19 (0.01.5) N 15

Results reported as: Odds ratio (probability of a positive outcome with a positive risk factor; P value for calculated odds ratio; 95% condence interval for odds ratio (in parentheses); number of patients included in logistic regression. Unless otherwise specied, odds ratios were determined using univariate logistic regression analysis. * Odds ratio calculated using Fishers exact test; condence interval calculated using Corneld approximation for zero cells. Insufcient data for analysis (95% condence interval found to be 0 ). Results reported as odds ratio per month difference in duration of symptoms. Results reported as odds ratio per 10-year difference in age. Results reported as odds ratio of men as compared to women.

an average of 3 years before onset of CES. Trauma was associated with 62% of the cases. The location of the lumbar disc herniations are shown in Table 4. The postoperative outcomes of all patients included in the study are shown in Table 5. The six postoperative outcomes were regressed on the 13 preoperative variables. The OR and P for each regression are shown in Table 3 (parts I and II). Signicant associations included a worsened prognosis for urinary continence in patients who had a history of preoperative chronic low back pain or in patients with preoperative rectal dysfunction. The prognosis for rectal function after surgery worsened with a history of chronic low back pain. In addition, older patients had a worsened prognosis for resolution of sexual function. The prognosis for return of sensory decit after surgery worsened with a history of preoperative rectal dysfunction. Specically, patients who had a history of chronic low back pain were at 11 times the risk of continuing to have a urinary decit after surgery (95% CI for OR 1.5 100.0) and 25 times the risk of continuing to have rectal dysfunction after surgery (95% CI for OR 2.0 333.3). Patients with preoperative rectal dysfunction were at no less than 1.15 times the risk of continuing to have a urinary decit after surgery, and the 95% CI for the OR

extended to innity. Patients who were older by 10 years were at 2.6 times the risk of continuing to have sexual dysfunction after surgery (95% CI for OR 1.15.9). Patients with preoperative rectal dysfunction were at 10 times the risk of continuing to have sensory decit after surgery (95% CI for OR 1.2100.0). The ve times to decompression were compared with each other for the six postoperative outcomes, listed as y1 through y6. For each predictor and each outcome, an OR and P were recorded. These results are listed in Table 6. There was no signicant difference in outcomes among the three groups that had decompression performed at more than 48 hours after onset. Thus, these groups were combined into one group (more than 48 hour group), and a new table was constructed (Table 7. There were signicant differences between the less than 24-hour and the more than 48-hour groups, and the 24 48-hour group and the more than 48-hour group. However, there was no signicant difference between the less than 24hour and 24 48-hour groups. Therefore, these were combined into one less than 48-hour group. Table 8 compares the less than 48-hour and the more than 48hour groups. A univariate logistic regression analysis was performed for each postoperative outcome comparing these two groups. There was a signicant improve-

1518 Spine Volume 25 Number 12 2000

Table 3. Logistic Regression of Postoperative Outcomes on Preoperative Variables. Part II

Preop Weakness Resolution of pain OR 1.8 P 0.45 (0.408.1) N 63 OR 0.94 P 0.91 (0.302.9) N 75 N 76 Preop Sensory Decit OR 1.5 P 0.73 (0.1515.1) N 57 OR 0.93 P 0.96 (0.0615.4) N 91 OR 0.0 P 0.56 (0.03.7) N 62 OR 0.17 P 0.09 (0.021.3) N 149 N 51 Preop Loss of Reexes OR 0.0 P 1.0 (0.016.5) N 33 OR 0.78 P 0.80 (0.125.3) N 43 N 25 Preop Rectal Dysfunction OR 0.76 P 0.75 (0.144.0) N 60 OR 0.1 P 0.04 (0.010.85) N 72 OR 0.0 P 0.08 (0.00.99) N 52 OR 0.0 P 0.04 (0.00.87) N 95 N 14

Resolution of sensory decit

Resolution of motor decit

Resolution of urinary decit

OR 1.1 P 0.93 (0.343.2) N 109 OR 0.57 P 0.60 (0.074.6) N 18 OR 0.33 P 0.27 (0.052.4) N 22

OR 0.46 P 0.28 (0.111.9) N 61 OR 0.42 P 0.52 (0.036.1) N 14 OR 0.0 P 0.19 (0.01.0) N 14

Resolution of sexual dysfunction

Resolution of rectal dysfunction

OR 0.25 P 0.27 (0.023.0) N 48

N 23

Results reported as: Odds ratio (probability of a positive outcome with a positive risk factor); P value for calculated odds ratio; 95% condence interval for odds ratio (in parentheses); number of patients included in logistic regression. * Odds ratio calculated using Fishers exact test; condence interval calculated using Corneld approximation for zero cells. Insufcient data for analysis (95% condence interval found to be 0 ).

ment in resolution of sensory decit, resolution of motor decit, resolution of urinary incontinence, and resolution of rectal dysfunction when decompression was performed within 48 hours compared with after 48 hours. Specically, patients who underwent surgery 48 hours or more after onset of CES, when compared with patients who underwent surgery within 48 hours, were at 2.5 times the risk of continuing to have a urinary decit, 9.1 times the risk of continuing to have a motor decit, 9.1 times the risk of continuing to have rectal dysfunction, and 3.5 times the risk of continuing to have a sensory decit. The 95% CIs for the ORs are listed in Table 8. Discussion Cauda equina syndrome is a complex of low back pain, bilateral sciatica, saddle anesthesia, and motor weakness Table 4. Location of Cauda Equina Syndrome Lumbar Disc Herniations
Level of Lumbar Disc Herniation L1L2 L2L3 L3L4 L4L5 L5S1 27% 9% 26% 16% 22%

in the lower extremities that progresses to paraplegia with rectal and urinary incontinence.12,23,50,93,98,106 Although Mixter and Barr65 are thought to be the rst to report this clinical syndrome in the English literature in 1934, Krause and Oppenheim51 were probably reporting CES earlier with a misinterpretation of a herniated lumbar disc as an extradural enchondroma in 1909. Clinical disease states almost always manifest as a spectrum of disorders, and CES is no exception. The clinical presentation of CES has varied from chronic back pain and sciatica that gradually progresses to a loss of urinary function, to acute trauma-related sciatic pain with immediate problems with vesicular control.12,45,50,77,92,100,106 The current study identied this variety of presentations. Most authors have thought that the onset of CES is heralded by the onset of disturbances of urinary function and/or rectal disorders, and this is how it was dened in the current study.50,57,93,100 Just as the presentation of CES can vary, so does the presentation of these vesicular abnormalities. Nielsen et al68 described 26 patients with

Table 5. Postoperative Outcomes

Pain relief Motor function Urinary continence Sexual function Rectal function Sensory restoration 83% 75% 73% 67% 64% 56%

Meta-Analysis of Cauda Equina Syndrome Ahn et al 1519

Table 6. Comparison of Times to Decompression

24 Hours 24 hours X y1: y2: y3: y4: y5: y6: OR OR OR OR OR OR 2448 Hours 1.75 1.50 2.00 0.72 1.49 0.67 48 Hours11 Days N N N N N N 15 32 38 66 12* 13 y1: y2: y3: y4: y5: y6: y1: y2: y3: y4: y5: y6: OR OR OR OR OR OR OR OR OR OR OR OR 0.54 9.00 11.9 4.09 * N 14.0 0.31 5.99 3.25 4.22 * N 20.9 11 Days1 Month y1: y2: y3: y4: y5: y6: y1: y2: y3: y4: y5: y6: y1: y2: y3: y4: y5: y6: OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR 1.17 3.30 18.5 2.80 5.99 2.00 0.67 2.20 9.30 2.89 3.99 3.00 2.17 0.37 1.56 0.22 * N 0.14 1 Month y1: y2: y3: y4: y5: y6: y1: y2: y3: y4: y5: y6: y1: y2: y3: y4: y5: y6: y1: y2: y3: y4: y5: y6: OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR OR 0.41 7.80 6.99 0.93 * N 4.66 0.24 5.20 3.50 0.96 * N 7.00 0.76 0.87 0.58 .068 * N 0.33 0.35 2.36 0.37 0.33 * N 2.33

P P P P P P

0.64 0.61 0.59 0.97 0.79 0.77

P 0.56 N 24 P .002 N 44 P 0.007 N 43 P 0.009 N 84 13 P 0.04 N 17 P 0.31 N 21 P 0.20 N 36 P 0.14 N 21 P 0.09 N 48 11 P 0.05 N 12
X

P P P P P P P P P P P P

0.88 N 21 0.078 N 41 0.001 N 44 0.081 N 77 0.17 N 15 0.52 N 15 0.71 N 18 0.295 N 33 0.062 N 22 0.22 N 41 0.30 N 13 0.44 N 10 N N N N 27 45 27 59

P 0.42 N 28 P 0.005 N 38 P 0.08 N 36 P 0.92 N 82 0 P 0.12 N 19 P 0.21 N 125 P P P 0 P P P P P 0 P P P P P 0 P

X 0.04 N 30 0.36 N 14 0.97 N 46 0.15 N 14 0.80 0.84 0.60 0.49 N N N N 34 42 19 64

2448 hours x X

48 hours11 days

P 0.44 P 0.12 P .057 P .022 14 P 0.15

X

N 14

0.39 N 18 0.30 0.21 0.34 0.12 N N N N 31 39 20 57

11 days1 month

0.43 N 16

1 month

Results reported as: Odds ratio (comparing row variable versus column variable); P value for calculated odds ratio; number of patients used in analysis. * Insufcient data for calculation.

CES. Urinary symptoms varied and included altered urethral sensation, loss of desire to void, poor stream, feeling of retention, and micturition by straining.68 Cauda equina syndrome occurs in approximately 2% of cases of herniated lumbar disc.50,102 Because of the infrequency of this disorder, early studies were limited to case reports.77,45,65,95 More recent studies have been small series, with results that indicate that prognosis improves with earlier decompression of CES. Dinning and Schaeffer23 examined 14 patients with CES, 9 underwent

decompression within 24 hours of urinary paralysis and 5 at times longer than 24 hours after onset.23 Urinary disturbances improved to a greater degree in the patients who underwent decompression within 24 hours. Nielsen et al68 conducted a similar study in 21 patients with urodynamic studies performed on follow-up. It appeared that detrusor function return was greatest in patients who had decompression within 48 hours of onset of symptoms.68 Shapiro93 surgically treated 14 patients with CES and found a 100% resolution of urinary and

Table 7. Comparison of Times to Decompression

24 Hours 24 hours x y1: y2: y3: y4: y5: y6: OR OR OR OR OR OR 2448 Hours 1.75 1.50 2.00 0.72 1.49 0.67 48 Hours N N N N N N 15 32 38 66 12 13 y1: y2: y3: y4: y5: y6: y1: y2: y3: y4: y5: y6: OR OR OR OR OR OR OR OR OR OR OR OR 0.60 5.72 13.1 3.35 4.36 7.34 0.34 3.82 6.59 3.46 2.91 11.1

P P P P P P

0.64 0.61 0.59 0.97 0.79 0.77

P P P P P P P P P P P P

0.57 N 57 0.003 N 84 0.001 N 63 0.007 N 169 0.192 N 45 0.02 N 42 0.26 N 54 0.04 N 76 0.09 N 51 0.113 N 133 0.36 N 43 0.05 N 37

2448 hours x x

48 hours

Results reported as: Odds ratio (comparing row variable versus column variable); P value for calculated odds ratio; number of patients used in analysis. y1 resolution of pain; y2 resolution of sensory decit; y3 resolution of motor decit; y4 resolution of urinary dysfunction; y5 resolution of sexual dysfunction; y6 resolution of rectal dysfunction.

1520 Spine Volume 25 Number 12 2000

Table 8. Decompression After 48 Hours Vs. Before 48 Hours

Surgery Performed 48 Hrs (as compared to 48 hrs) Resolution of pain OR 0.51 P 0.338 (0.132.00) N 66 OR 3.45 P 0.005 (1.458.33) N 98 OR 9.09 P 0.001 (2.5633.33) N 73 OR 2.5 P 0.01 (1.195.26) N 189 OR 3.85 P 0.09 (0.792.06) N 51 OR 9.09 P 0.003 (2.1333.3) N 47

Resolution of sensory decit

Resolution of motor decit

Resolution of urinary decit

Resolution of sexual dysfunction

Resolution of rectal dysfunction

Results reported as: Odds ratio (probability of a positive outcome with a positive risk factor); P value for calculated odds ratio; 95% condence interval for odds ratio (in parentheses); number of patients used in analysis.

stool incontinence when decompression was performed within 48 hours of onset and a 33% resolution in surgery after 48 hours. Results in a subsequent study of 44 patients demonstrated a signicantly greater chance for long-term motor and urologic dysfunction in patients treated for CES more than 48 hours after onset by 2 analysis. None of these studies, except for the most recent study of Shapiro,94 demonstrated statistical signicance. The current study attempted to conrm or refute the conclusion by these investigators that decompression performed within 48 hours of onset of CES resulted in improved postoperative functional outcomes. This metaanalysis was performed to improve the statistical power of the available data in the literature. Surgeons have found that time to recovery from CES after surgery can vary.23,45 Reported recovery times ranged from months to years in the current study.50,93,94,100 A study was performed in dogs by Delamarter et al20 in which CES was mechanically induced with surgical constriction bands. They demonstrated similar recoveries 6 weeks after compression, regardless of length of compression. A limitation in the current study was the range of time of follow-ups reported. Because these varied from months to years, it is possible that patients reported to have experienced a partial recovery had a nondocumented improvement after the last recorded follow-up. Jennett45 stated that although most patients improve in the rst 2 years after decompression, some patients continued to improve clinically as long as

5 years after surgery. Surgical decompressions performed in these studies also varied. Aho et al1 performed a hemilaminectomy in 19 patients. In Kostuik et al,50 30 of 31 patients underwent wide laminectomy and bilateral decompression. Dinning and Schaeffer23 and Schaeffer88 reported that intradural surgery was necessary in 18% of their patients. Shapiro93,94 and Jennett45 did not enter the dura in any of their patients in their separate series. It is possible that these different treatments produced different outcomes; however, the authors thought that the common key element of the operations was an adequate decompression of the neural elements. Each author in the studies reviewed reported that this was the case. In addition, the authors believe that there was probably coexisting disease in some patients reviewed, including arachnoid scarring and spinal stenosis. The information in the studies reviewed, however, was inadequate to control for these disorders. The primary difculty with a meta-analysis is that different studies report data in different ways. A large initial volume of data must be evaluated, and ineffective and incomplete reports must be immediately discarded. The remaining information must be carefully used to conrm or refute a hypothesis. Some authors accurately reported motor recovery by level and grading and urinary function with postoperative cystometric results.93,100 Others reported motor recovery ineffectively, such as ambulating with a cane.45,65,77 Insufcient information was immediately discarded in the current study. Data were categorized into predetermined pre- and postoperative variables. Each study provided a different permutation of these variables. Some studies were retrospective reviews, and data obtained were incomplete. Others, especially case reports, simply failed to accurately report a complete neurologic examination at follow-up. The analysis performed was able to associate outcome variables to length of time to surgery with ve groups: less than 24 hours, 24 48 hours, 210 days, 11 days1 month, and more than 1 month. The onset of CES was strictly dened by the authors as the time when urinary dysfunction took place. Motor, sensory, rectal, and urinary recoveries were recorded as positive only if full recovery was reported. Incomplete recovery was recorded as a failure to recover. There was no difference in outcomes between patients treated less than 24 hours after onset of CES and those treated within 24 48 hours. Likewise, there was no difference in outcomes in the three groups of patients treated after 48 hours. However, there was a signicant advantage to treating patients within 48 hours as opposed to later than 48 hours, with improved outcomes in resolution of sensory decit, motor decit, urinary function, and rectal function. The presence of preoperative chronic low back pain was associated with poorer outcomes in urinary and rectal function. Preoperative rectal dysfunction was associated with a worsened outcome in

Meta-Analysis of Cauda Equina Syndrome Ahn et al 1521

urinary continence. In addition, older patients were less likely to fully regain sexual function after surgery. Key Points Cauda equina syndrome is considered an absolute indication for acute surgical treatment of lumbar disc herniation. Timing of surgical decompression is controversial, with results in certain studies showing that delayed surgery may provide a satisfactory outcome. A meta-analysis of surgical outcomes of CES secondary to lumbar disc herniation was performed. A signicant advantage was shown to treating patients within 48 hours compared with more than 48 hours after the onset of CES symptoms.

References
1. Aho AJ, Auranen A, Pesonen K. Analysis of cauda equina symptoms in patients with lumbar disc prolapse. Acta Chir Scand 1969;135:41320. 2. Andersen JT, Bradley WE. Neurogenic bladder dysfunction in protruded lumbar disk and after laminectomy. Urology 1976;8:94 6. 3. Baba H, Uchida K, Furusawa N, et al. Posterior limbus vertebral lesions causing lumbosacral radiculopathy and the cauda equina syndrome. Spinal Cord 1996;34:42732. 4. Barr JS. Sciatica caused by intervertebral disc lesion. J Bone Joint Surg 1937;19:323 42. 5. Bartels RHMA, de Vries J. Hemi-cauda equina syndrome from herniated lumbar disc: A neurosurgical emergency? Can J Neurol Sci 1996;23:296 9. 6. Blikra G. Intradural herniated lumbar disc. J Neurosurg 1969;31:676 9. 7. Bonaroti EA, Welch WC. Posterior epidural migration of an extruded lumbar disc fragment causing cauda equina syndrome: clinical and magnetic resonance imaging evaluation. Spine 1998;23:378 81. 8. Borovich B. Zaaroor M, Gruszkiewicz J. The syndrome of the central L-3herniated disc with special emphasis on motor involvement. Acta Neurochir 1984;70:11525. 9. Bors E. Neurogenic bladder. Urol Surv 1957;7:177. 10. Bruggen A. Massive extrusions of the lumbar intervertebral discs. Surg Gynecol Obstet 1945;81:269 77. 11. Chauhan R. Cauda equina syndrome. Br J Hosp Med 1994;4:193. 12. Choudhury AR, Taylor JC. Cauda equina syndrome in lumbar disc disease. Acta Orthop Scand 1980;51:4939. 13. Ciapetta P, Delni R, Cantore GP. Intradural lumbar disc hernia: Description of three cases. Neurosurgery 1981;8:104 7. 14. Coscia M, Leipzig T, Cooper D. Acute cauda equina syndrome: Diagnostic advantage of MRI. Spine 1994;19:475 8. 15. Craig DP. Strangulated obturator hernia. Br J Surg 1962;49:426. 16. Crawfurd EJP, Baird PRE, Clark AL. Cauda equina and lumbar nerve root compression in patients with AIDS. J Bone Joint Surg [Br] 1987;69:36 7. 17. Dandy WE. Loose cartilage from intervertebral disk simulating tumor of the spinal cord. Johns Hopkins Hospital 1929;660 72. 18. Dandy WE. Serious complications of ruptured intervertebral disks. JAMA 1942;119:474 7. 19. Deen HG. Concise review for primary-care physicians: Diagnosis and management of lumbar disk disease. Mayo Clin Proc 1996;71:2837. 20. Delamarter RB, Sherman JE, Carr JB. Volvo award in experimental studies. Cauda equina syndrome: Neurologic recovery following immediate, early, or late decompression. Spine 1991;16:10229. 21. Denny-Brown D, Robertson EG. On the physiology of micturition. Brain 1933;58:256. 22. Deyo RA, Loeser JD, Bigos SJ. Herniated lumbar intervertebral disk. Ann Intern Med 1990;112:598 603.

Reference Met the inclusion criteria and was used in the meta-analysis. Unmarked listings did not meet the inclusion criteria for the meta-analysis.

23. Dinning TAR, Schaeffer HR. Discogenic compression of the cauda equina: A surgical emergency. Aust NZ J Surg 1993;63:92734. 24. Dyck P, Pheasant HC, Doyle JB, et al. Intermittent cauda equina compression syndrome: Its recognition and treatment. Spine 1977;2:75 81. 25. Emmet JL, Love JG. Vesical dysfunction caused by protruded lumbar disk. J Urol 1970;105:86 91. 26. Emmett JL, Love JG. Urinary retention in women caused by asymptomatic protruded lumbar disk: Report of 5 cases. J Urol 1968;99:597 606. 27. Eyre-Brook AL. A study of late results from disk operations: Present employment and residual complaints. Br J Surg 1952;39:289 96. 28. Fischer ED. Report of a case of ruptured intervertebral disc following chiropractic manipulation. Kentucky Med J 1943;41:14. 29. Floman Y, Wiesel SW, Rothman RH. Cauda equina syndrome presenting as a herniated disk. Clin Orthop 1980;147:234 7. 30. French D, Payne JT. Cauda equina compression syndrome with herniated nucleus pulposus. Ann Surg 1994;120:73. 31. Gallinaro P, Cartesegna M. Three cases of lumbar disc rupture and one of cauda equina associated with spinal manipulation (chiropraxis). Lancet 1983;1: 411. 32. Gindin RA, Volcan IJ. Rupture of the intervertebral disc producing cauda equina syndrome. Am Surg 1978;9:58593. 33. Goldthwait JE. The lumbo-sacral articulation: An explanation of many cases of lumbago, sciatica, and paraplegia. Boston Med Surg J 1911;164: 36572. 34. Graham GP, Moran CG, Jones DG, et al. Urinary dysfunction and the cauda equina syndrome. Hosp Med 1993;44:623. 35. Grynderup V. Cauda equina lesions from lumbar disc prolapse. Acta Neurol Scand 1970;43:267. 36. Gunasekera WSL, Richardson AE, Seneviratne KN, et al. Clinical correlation of urodynamic ndings in patients with localized partial lesions of the spinal cord and cauda equina. Surg Neurol 1984;21:148 54. 37. Gurdjian ES, Webster JE, Ostrowski AZ, et al. Herniated lumbar intervertebral discs: An analysis of 1176 operated cases. J Trauma 1961;1:158 76. 38. Haldeman S, Rubinstein SM. Cauda equina syndrome in patients undergoing manipulation of the lumbar spine. Spine 1992;17:1469 73. 39. Hellstrom P, Kortelainen P, Kontturi M. Late urodynamic ndings after surgery for cauda equina syndrome caused by a prolapsed lumbar intervertebral disk. J Urol 1986;135:308 12. 40. Hellstrom P, Tammela TLJ, Niinimaki TJ. Voiding dysfunction and urodynamic ndings in patients with lumbar spinal stenosis and the effect of decompressive laminectomy. Scand J Urol Nephrol 1995;29:16772. 41. Hlavin ML, Hardy RW Jr. Lumbar disc disease. Neurosurg Q 1991;1:29 53. 42. Hooper J. Low back pain and manipulation paraparesis after treatment of low back pain by physical methods. Med J Aust 1973;1:549 57. 43. Hurme M, Alaranta H, Torma T, et al. Operated Lumbar disc herniation: Epidemiological aspects. Ann Chir Gynaecol 1983;72:33 6. 44. Jefferson AA, Schlapp W. Some effects of repetitive stimulation of afferents on reex conduction: The spinal cord. Ciba Foundation Symposium. Boston: Little, Brown & Co., 1953. 45. Jennet WB. A study of 25 cases of compression of the cauda equina by prolapsed intervertebral discs. J Neurol Neurosurg Psychiatry 1956;19:109 116. 46. Jones DL, Moore T. The types of neuropathic bladder dysfunction associated with prolapsed lumbar intervertebral discs. Br J Urol 1973;45:39 43. 47. Kennedy F, Elsberg CA, Lambert CI. A peculiar disease of the nerves of the cauda equina. Am J Med Sci 1914;147:645 67. 48. Kontturi M, Harviainen S, Larmi TKI. Atonic bladder in lumbar disk herniation. Acta Chir Scand Suppl 1966;357:2325. 49. Konturri M. Investigations into bladder dysfunction in prolapse of lumber intervertebral disc. Ann Chir Gynaecol Fenn Suppl 1968;162:153. 50. Kostuik JP, Harrington I, Alexander D, et al. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg [Am] 1986;68:386 91. 51. Krause F, Oppenheim H. Uber Einklembug bzw., Strangulation der cauda equina. Deutsch Med Wochenschr 1909;35:697. 52. Lafuente DJ, Andrew J, Joy A. Sacral sparing with cauda equina compression from central lumbar intervertebral disc prolapse. J of Neurol Neurosurg Psychiatry 1985;48:579 81. 53. Lapides J, Sweet RB, Levis LW. Role of striated muscle in urination. J Urol 1957;77:247. 54. Leikkonen O. Subtotal spondylolisthesis with cauda equina syndrome and disk protrusion treated with double graft fusion. Ann Chir Gynaecol Fenn 1963; 52:654. 55. Loew F, Caspar W. Surgical approach to lumbar disc herniation. Adv Tech Stand Neurosurg 1978;5:15374. 56. Long DM. Decision making in lumbar disc disease. Clin Neurosurg 1992; 39:36 51.

1522 Spine Volume 25 Number 12 2000

57. Love JG, Emmet JL. Asymptomatic protruded lumbar disk as a cause of urinary retention: Preliminary report. Mayo Clin Proc 1967;42:249 57. 58. Lyons A, Wise BL. Subarachnoid rupture of intervertebral disc fragments. J Neurosurg 1961;18:242 4. 59. Malloch JD. Acute retention due to intervertebral disc prolapse. Br J Urol 1965;37:578. 60. Malmivaara A, Pohjola R. Cauda equina syndrome caused by chiropraxis on a patient previously free of lumbar spine symptoms. Lancet 1982;2:986 7. 61. Markowitz HD, Dolce DT. Cauda equina syndrome due to sequestrated recurrent disk herniation after chiropractic manipulation. Orthopedics 1997;20: 6523. 62. Mathew P, Todd NV. Diagnosis of intradural conus and cauda equina tumors. J Neurol Neurosurg Psychiatry 1993;18:69 74. 63. McLaren AC, Bailey SI. Cauda equina syndrome: A complication of lumbar discectomy. Clin Orthop 1986;204:1439. 64. McNeill TW. Cauda equina syndrome in spinal stenosis. In: Anderson GBM, McNeill TW, eds. Lumbar Spinal Stenosis. St. Louis: Mosby-Year Book, 1992;219 24. 65. Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal. N Engl J Med 1934;211:210 4. 66. Mosdal C, Iversen P, Iversen-Hansen R. Bladder neuropathy in lumbar disc disease. Acta Neurochir 1979;46:281 6. 67. Muellner SR. The voluntary control of micturition in man. J Urol 1958;80: 473. 68. Nielsen B, de Nully M, Schmidt K, et al. A urodynamic study of cauda equina syndrome due to lumbar disc herniation. Urol Int 1980;35:16770. 69. OConnnel JEA. Protrusions of the lumbar intervertebral discs: A clinical review based on ve hundred cases treated by excision of the protrusion. J Bone Joint Surg [Br] 1951;33:8 30. 70. OFlynn KJ, Murphy R, Thomas DG. Neurogenic bladder dysfunction in lumbar intervertebral disc prolapse. Br J Urol 1992;69:38 40. 71. OLaoire SA, Crockard HA, Thomas DG. Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disc prolapse. BMJ 1981;282:1852 4. 72. Ohaegbulam SC. Cauda equina epidural meningioma. Acta Neurochir 1979;46:28791. 73. Paterson JE, Gray W. Herniated nucleus pulposus: The free fragment. Br J Surg 1952;39:509 13. 74. Perner A, Anderson JT, Juhler M. Lower urinary tract symptoms in lumbar root compression syndromes: A prospective survey. Spine 1997;22:26937. 75. Peyser E, Harari A. Intradural rupture of lumbar intervertebral disk: Report of two cases with review of the literature. Surg Neurol 1977;8:95 8. 76. Poppen JL. The herniated intervertebral disk: An analysis of 400 veried cases. N Engl J Med 1945;232:2115. 77. Rai B, Chopra BK, Gupta RK. Cauda equina syndrome: A clinical study. J Indian Med Assoc 1973;60:47 8. 78. Rai B, Chopra BK, Gupta RK. Cauda equina syndrome: A clinical study. J Indian Med Assoc 1973;60:47 8. 79. Ravindran M. Cauda equina compression presenting as spontaneous priapism. J Neurol Neurosurg Psychiatry 1979;42:280 2. 80. Richard J. Disk rupture with cauda equina syndrome after chiropractic adjustment. NY State J Med 1967;67:2496 8. 81. Robinson RG. Massive protrusions of lumbar disks. Br J Surg 1965;52: 858 65. 82. Rongxum Z. Spinal canal block caused by central disc protrusion. Chin Med J 1980;93:501 6. 83. Rose DK. CPSC: Cystometry. Acta Urol Belg 1961;29:5. 84. Rosomoff HL, Johnston JDH, Gallo AE, et al. Cystometry as an adjunct in the evaluation of lumbar disc syndromes. J Neurosurg 1970;33:6774. 85. Rosomoff HL, Johnston JDH, Gallo AE, et al. Cystometry in the evaluation of nerve root compression in the lumbar spine. Surg Gynecol Obstet 1963;11: 26370. 86. Rosomoff HL. The neurogenic bladder of lumbar disc syndromes. Trans Am Neurol Assoc 1965;89:249 51. 87. Ross JC, Jameson RM. Vesical dysfunction due to prolapsed disc. BMJ 1971;3:752 4. 88. Schaeffer HR. Cauda equina compression resulting from massive lumbar disc extrusion. Aust NZ J Surg 1966;35:300 6. 89. Schatzker J, Pennal GF. Spinal stenosis a cause of cauda equina compression. J Bone Joint Surg [Br] 1968;50:606. 90. Schlesinger EB, Taveras JM. Factors in the production of cauda equina syndromes in lumbar discs. Trans Am Neurol Assoc 1953;78:2635. 91. Schoenecker PL, Cole HO, Herring JA, et al. Cauda equina syndrome after in situ arthrodesis for severe spondylolisthesis at the lumbosacral junction. J Bone Joint Surg [Am] 1990;72:369 77. 92. Scott PJ. Bladder paralysis in cauda equina lesions from disc prolapse. J Bone Joint Surg [Br] 1965;47:224 35. 93. Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Neurosurg 1993;32:7437. 94. Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Spine 2000;25:348 52. 95. Shephard RH. Diagnosis and prognosis of cauda equina syndrome produced by protrusion of lumbar disk. BMJ 1959;1:1434 9. 96. Spickard III, A. Low back pain with progressive weakness: A case of cauda equina syndrome from lumbar disc herniation. Tenn Med 1996;89:338 9. 97. Susset JG, Peters ND, Cohen SI, et al. Early detection of neurogenic bladder dysfunction caused by protruded lumbar disc. Urology 1982;20:4613. 98. Taher Y, Sorour O, El-Shae I, et al. Cauda equina lesion due to prolapsed lumbar intervertebral discs. J Egypt Med Assoc 1966;49:336 46. 99. Tandon PN, Sankaran B. Cauda equina syndrome due to lumbar disc prolapse. Indian J Orthop 1967;1:1129. 100. Tay ECK, Chacha PB. Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina. J Bone Joint Surg [Br] 1979;61:43 6. 101. Teng P, Papatheodorou C. Intrathecal dislocation of lumbar intervertebral disc. Neurochirurgia 1964;7:57 63. 102. Ver Brugghen A. Massive extrusions of the lumbar intervertebral discs. Surg Gynecol Obstet 1945;81:269 77. 103. Walker JL, Schulack D, Murtagh R. Midline disk herniations of the lumbar spine. South Med J 1993;86:137. 104. Wetzel FT. Surgery for herniated vertebral disks. JAMA 1996;275:513 4. 105. Wilson PJE. Cauda equina compression due to intrathecal herniation of an intervertebral disk. Br J Surg 1962;40:423 6. 106. Yaxley RP. Acute urinary retention due to intervertebral disc collapse. Br J Urol 1965;37:578.

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