Lumbar decompression surgery for cauda equina syndrome — comparison of complication rates between daytime and overnight operating

Acta Neurochirurgica (2022) 164:1203–1208

Purpose To investigate the incidence of complications from lumbar decompression ± discectomy surgery for cauda equina syndrome (CES), assessing whether time of day is associated with a change in the incidence of complications.

Methods Electronic clinical and operative notes for all lumbar decompression operations undertaken at our institution for CES over a 2-year time period were retrospectively reviewed. “Overnight” surgery was defined as any surgery occurring between 18:00 and 08:00 on any day. Clinicopathological characteristics, surgical technique, and peri/post-operative complications were recorded. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals.

Results A total of 81 lumbar decompression operations were performed in the 2-year period and analysed. A total of 29 (36%) operations occurred overnight. Complete CES (CESR) was seen in 13 cases (16%) in total, 7 of whom underwent surgery during the day. Exactly 27 complications occurred in 24 (30%) patients. The most frequently occurring complication was a dural tear (n = 21, 26%), followed by post-operative haematoma, infection, and residual disc. Complication rates in the CESR cohort (54%) were significantly greater than in the CES incomplete (CESI) cohort (25%) (p = 0.04). On multivariable analysis, overnight surgery was independently associated with a significantly increased complication rate (OR 2.83, CI 1.02–7.89).

Conclusions Lumbar decompressions performed overnight for CES were more than twice as likely to suffer a complication, in comparison to those performed within daytime hours. Our study suggests that out-of-hours operating, particularly at night, must be clinically justified and should not be influenced by day-time operating capacity.

Are There Any Risk Factors Associated with the Presence of Cauda Equina Syndrome in Symptomatic Lumbar Disk Herniation?

World Neurosurg. (2020).

Risk factors for developing cauda equina syndrome (CES) caused by lumbar disk herniation (LDH) remain controversial and have not been established yet. The aim of the study was to investigate whether there is a relationship among age, sex, body mass index (BMI), or the degree of spinal canal compromise and the presence of CES in patients undergoing lumbar microdiskectomy.

METHODS: Between 2015 and 2019, 506 patients who had an operation for LDH compressing the dural sac were prospectively identified. The “prolapse-to-canal ratio” (PCR) was calculated as a proportion of the cross-sectional area of the disk prolapse compared with the total crosssectional area of the spinal canal.

RESULTS: In total, 35 CES (6.9%) patients were identified. Multivariate logistic regression, adjusted for age, gender, BMI, and PCR, shows that only PCR was associated with the presence of CES (P < 0.001, area under the curve 0.7431). BMI was not associated with an increased risk of CES.

CONCLUSIONS: This study demonstrates a significant correlation between the size of LDH relative to size of the spinal canal and the presence of CES. A finding of LDH causing >60% obstruction of the spinal canal should be considered a red flag, and such patients need to be watched more closely.

Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome

J Neurosurg Spine 31:906–913, 2019

Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications.

METHODS A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported.

RESULTS The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT).

CONCLUSIONS There are still insufficient data to support stem cell injections for back pain. Additional RCTs with longterm follow-up are necessary before statements can be made regarding the efficacy and safety.


Lumbar disk herniation during pregnancy: a review on general management and timing of surgery

Acta Neurochir (2018) 160:1361–1370

Objective Provide an overview of existing management strategies to suggest a guideline for surgical management of lumbar disk herniation in pregnant women based on time of presentation.

Methods We performed a narrative review on the topic using the PubMed database. A total of 63 relevant articles published after 1992 were identified, of which 17 fulfilled selection criteria.

Results A total of 22 published cases of spine surgery for disk herniation during pregnancy were found in 17 studies on the topic. Prone positioning was reported in the majority of cases during the first and early second trimester. C-sections were performed prior to spine surgery in the prone position for the majority of patients operated during the third trimester. The left lateral position with continued pregnancy was preferred during the latter half of the second trimester when delivery of the fetus cannot yet be performed but surgery is indicated.

Conclusion Spine surgery during pregnancy is a rare scenario but can be performed safely when needed if providers adhere to general guidelines. Surgical approaches and overall management are influenced by the stage of pregnancy.

Anterior lumbar discectomy and fusion for acute cauda equina syndrome caused by recurrent disc prolapse

J Neurosurg Spine 27:352–356, 2017

There is a lack of information and consensus regarding the optimal treatment for recurrent disc herniation previously treated by posterior discectomy, and no reports have described an anterior approach for recurrent disc herniation causing cauda equina syndrome (CES). Revision posterior decompression, irrespective of the presence of CES, has been reported to be associated with significantly higher rates of dural tears, hematomas, and iatrogenic nerve root damage.

The authors describe treatment and outcomes in 3 consecutive cases of patients who underwent anterior lumbar discectomy and fusion (ALDF) for CES caused by recurrent disc herniations that had been previously treated with posterior discectomy. All 3 patients were operated on within 12 hours of presentation and were treated with an anterior retroperitoneal lumbar approach. Follow-up ranged from 12 to 24 months. Complete retrieval of herniated disc material was achieved without encountering significant epidural scar tissue in all 3 cases. No perioperative infection or neurological injury occurred, and all 3 patients had neurological recovery with restoration of bladder and bowel function and improvement in back and leg pain.

ALDF is one option to treat CES caused by recurrent lumbar disc prolapse previously treated with posterior discectomy. The main advantage is that it avoids dissection around epidural scar tissue, but the procedure is associated with other risks and further evaluation of its safety in larger series is required.

Conus medullaris and cauda equina tumors

Conus and cauda equina tumors

J Neurosurg Spine 20:335–343, 2014

Intradural cauda equina and conus medullaris tumors (CECMTs) are rare. Only a few large clinical series exist to date. Therefore, clinical symptoms, surgical complications, and outcomes are poorly understood. The aim of the present study was to evaluate outcome after surgery of CECMTs and to identify the factors associated with a worse clinical prognosis based on the results of a series with sufficiently high number of cases.

Methods. All cases of intradural CECMTs treated surgically at the authors’ department between March 2006 and May 2012 were retrospectively evaluated. Arachnoid cysts and multifocal tumors were excluded. Sixty-eight adult patients met the inclusion criteria (35 female and 33 male patients; median age 56 years). Follow-up data were available for 72% (n = 49) in a median period of 9 months.

Results. Overall, 18 tumors were located intramedullary and 50 extramedullary. The majority were nerve sheath tumors (n = 27), ependymomas (n = 17), and meningiomas (n = 9). The most common preoperative symptom was pain. The rate of new transient postoperative impairment was 18% (n = 12), and new permanent deficits were observed in only 6% (n = 4). Overall neurological improvement was achieved in 62%. The reversibility of preoperative symptoms was related to the interval between the time of symptom onset and the time of surgery and to the presence of preoperative neurological deficits. Surgery of ependymoma and carcinoma metastases was associated with a higher rate of morbidity.

Conclusions. Intradural CECMTs present as a group of tumors with varying histological features and clinical symptoms. Symptomatic manifestation is usually unspecific, mimicking degenerative lumbar spine syndromes. Despite a significant risk of transient deterioration, early surgery is advisable because more than 94% of patients maintain at least their preoperative status and more than 60% improve during follow-up. The reversibility of preoperative symptoms is related to the duration between symptom onset and surgery and to the presence of preoperative neurological deficits. The prognosis for recovery from cauda equina or conus medullaris syndrome is less favorable than for other deficits. Surgery of ependymoma is associated with a higher morbidity rate than other benign entities.

Cauda equina syndrome: a review of the current clinical and medico-legal position

Eur Spine J (2011) 20:690–697. DOI 10.1007/s00586-010-1668-3

Cauda equina syndrome (CES) is a rare condition with a disproportionately high medico-legal profile. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration.

Review of the literature indicates that around 50–70% of patients have urinary retention (CES-R) on presentation with 30–50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression by a suitably experienced surgeon. Every effort should be made to avoid CES-I with its more favourable prognosis becoming CES-R while under medical supervision either before or after admission to hospital. The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage.

A full explanation and consent procedure prior to surgery is essential in order to reduce the likelihood of misunderstanding and litigation in the event of a persistent neurological deficit.