Cauda Equina Syndrome from a spinal surgery perspective

1. Cauda Equina Syndrome
• Spine Conference
• Tuesday Sepember 24, 2019

2. 39 year old woman
Cc: B sciatica perineal
anesthesia
HPI: 2 weeks of symptoms
(June 2017), she thought it
was MS
PMH: bipolar, gastic sleeve
120/40 2014,
SH: disability, lives alone
Exam: 5/5 ankle DF/PF

4. L3L4
L4L5

5. L5S1

6. Note the R S1 nerve root

7. Typical L5S1 disc herniation

9. cauda equina

10. Cauda Equina Syndrome

11. Pain
saddle anesthesia
sacral nerve root
dysfunction

17. Is DRE valid?
Spine 2015 Vol 40 No 15 p 1213
75 doctors, 30 control medical assistants
Score 0-5 where 0=20mm Hg and 5= 130mm
Normal is 60 and decreased is 30mm
Anorectal manometry reveals range
Squeeze test is 180mm, more accurate
64% correct

18. Orthopedics March 2012 Vol 34,
No 3, page e414
LexisNexis academic legal search
data base; 104 lawsuits found 15
qualified
6/15 in favor of plaintiff with mean
award $1.6M ($230k- $7.5M)
27% involved initial presentation
of loss of B/B control; 60%
presented to ER
time to surgery>48 hours a/w
plaintiff award 83%
14/15 cases had no rectal exam

19. Bladder/Urination symptoms
Lack of bladder fullness sensation
Urinary retention
Urination down thigh in women
Overflow incontinence

21. Sexual dysfunction:
• Men: decreased sensation, EF
• Women: decreased sensation,
urinary incontinence during
intercourse
• Worse with increased age

23. Spine 2000 June 15; 25(12):1515-22
meta-analysis
322 patients
chronic LBP worse B/B
bowel dysfunction worse urinary
older age worse sex function
<24 hours no better than 24-48 hours
all patients have same outcome >48 hours
significant difference in B/B function and
sensation for patients <48 hours and >48
hours

27. Sacral nerve
root
resections
• (bowel/bladder loss)
• B S2S5 100%
• Unilateral preservation of S3
33%/40%
• Bilateral S2 preservation
60%/75%
• Bilateral S2S3
preservation 0%/30%

29. Nicholas Vyner Todd, UK neurosurgeon,
Newcastly upon Tyne, UK
Categories:
1. Suspicious
2. Incomplete
3. Retention (urinary)
4. Complete
Br J Neurosurgery 2016 review article
158 papers
<24 hours surgery 89% normal bladder
<48 hours surgery 79% normal bladder
>48 hours surgery 44% normal bladder
Emergency MRI critical for suspicious patients
B sciatica is suspicious
Incomplete bladder dysfunction patients are
true emergencies
“out of hours” surgery carry increased
morbidity and mortality

31. Shanghai, china

32. E: Early: B symptoms lower extremity m/s
I: incomplete
R: retention

33. BLE pain
BLE
paresthesia
B motor LE
B sciatica
Perineal
paresethsia
Perineal pain
Reduction
bladder
Reduction
bowel
Bladder
dysfuction
Bowel
dysfunction
222 cases

34. 2000-2014 national database using icdm/cpt
codes for CES for disc, stenosis, tumor, hematoma
20k patients
Early <48 hours Late>48 hours
Routine d/c 48% 27%
Skilled facility 38% 57%
Mortality 0.18% 1.7%
Complications 20% 27%
Foley 1.8% 2.7%
Length of stay 6 days 9 days
Charges $71k $131k

35. Problem: physical exam is poor predictor for CES
Pre and postvoid bladder scan in predicting CES
6 months prospective, Nottingham UK; Spine 2019;44:1303
92 patients suspect CES, 18% nerve compression by MRI
53% sensitivity of anal tone to predict CES
82% sensitivity perianal numbness;92% negative predictive
value
PVR<200cc negative predictive value 98%, specificity 72% a d
sensitivity 94%

36. Thanks

43. Br J Neurosurgery 2017 Vol 31 no 3 p336
red flag is danger ahead, white flag is too late