Timing of Surgery For Cauda Equina Syndrome

There is much debate surrounding the timing of surgery with regards to cauda equina syndrome. However, it is widely accepted that the nerves must be surgically decompressed before a patient progresses to the complete stage.

CES: timing of surgery

Since the 1950s, medical experts have been debating the timeliness of surgical decompression with regards to cauda equina syndrome. Some believe there is no correlation between the timing of decompression and the eventual outcome, while some advocate that surgery must be performed within 48 hours of the onset of symptoms.

The idea that decompression surgery must be carried out within 48 hours was proposed by Shapiro in 2000. He studied 44 patients, 20 of which were operated on within 48 hours. Of these 20 patients, he found that:-

• The 18 patients who had surgery within 24 hours returned to full strength within one year;
• The two patients who underwent surgery between 24 to 48 hours regained 4/5 strength within two weeks;
• 95% of the patients had normal bladder function within six months;
• 100% of the men resumed normal sexual function, although the seven women reported difficultly achieving orgasm.

Of the 24 patients who underwent surgical decompression more than 48 hours after the onset of symptoms, he found that:-

• 58% had 0/5 to 2/5 weakness;
• 63% had to catheterise in the long-term;
• 71% had acute sciatic pain;
• 31% of unable to achieve an erection after one year.

These results evidently show that the outcome is more favourable in those who were operated upon within 24 to 48 hours. Nevertheless, a study carried out by Hussain in 2003 compared 20 patients, six of which were operated upon within 48 hours. He concluded that there was no significant difference in outcome between the two groups.

Urgent decompression surgery

There is no clear consensus as to when decompression surgery must be carried out if long-term complications are to be avoided. Despite this, the overwhelming majority of medical practitioners would accept the prognosis is more favourable in those who undergo surgery while the condition is still incomplete.

If there is a delay and complete urinary retention occurs, a patient is said to have complete cauda equina syndrome. At this stage the nerves will have sustained so much damage that any treatment is likely to prove ineffective. It is therefore preferable that surgery is performed within 24 to 48 hours, as long as a patient’s health and the presence of qualified staff allows for it.

If there is a delay because of medical error and this leads to complications that could otherwise have been prevented, there will be a case of medical negligence.

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