Published: 2017-08-24

Evaluation of relationship between timing of surgery and functional outcome considering the extent of neurological deficit in patients with cauda equina syndrome secondary to lumbar disc herniation

Anuj D. Bharuka, Rajendra Phunde, Hiren B. Patel


Background: Cauda equina syndrome (CES) is a rare but severe neurological disorder most commonly due to lumbar disc herniation. The role of urgent surgery in improving the outcome of patients with CES remains controversial.

Methods: In the present study retrospective evaluation of 44 patients with CES secondary to lumbar disc herniation treated at our hospital between 2009 and 2017 has been done. The patients were categorized into complete (CES-R) and incomplete (CES-I) types of CES and the relationship between timing of surgery and outcome were evaluated.

Results: Out of 44 patients, 28 patients presented with CES-I and 16 patients presented with CES-R. In patients with CES-I there was statistically significant difference (p=0.0001) in all observed surgical outcome between the patients operated within 48 hrs and those operated after 48 hrs. In patients with CES-R, no correlation was found between onset of symptoms and timing of surgery as recovery was partial in all the patients except 3 who completely recovered, irrespective of their operative times. (p=0.494).

Conclusions: Early diagnosis and treatment in form of emergency decompressive surgery done within 48 hours of onset of autonomic symptoms in CES-I patients can prevent further neurological damage and deterioration to CES-R. For CES-R patients operating within 48 hours made no difference to their outcome. However, necessary investigations and planned surgery by skilful surgeon should be arranged as soon as is reasonably possible for patients with CES-R. 


Cauda equina syndrome- CES-I & CES-R, Lumbar disc herniation, Surgical outcome

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Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal cord. N Engl J Med. 1934;211:210–4.

Tandon PN, Sankaran B. Cauda Equina syndrome due to lumbar disc prolapse. Indian J Orthop. 1967;1:112–9.

Gertzbein SD, Court-Brown CM, Marks P. The neurological outcome following surgery for spinal fractures. Spine. 1988;13:641–4.

Benzel EC, Hadden TA, Coleman JC. Civilian gunshot wound to the spinal cord and cauda equina. Neurosurgery. 1987;20:281–5.

Kostuik JP, Harrington I, Alexander D. Cauda equina syndrome and lumbar disc herniation. J Bone Joint Surg Am. 1986;68:386-391

Shapiro S. Cauda Equina syndrome secondary to lumbar disc herniation. Neurosurgery. 1993;32:743-7

Tay EK, Chacha PB. Midline prolapse of a lumbar intervertebral disc with compression of the cauda equina. J Bone Joint Surg Br. 1979;61:43–6.

Shepard RH. Diagnosis and prognosis of cauda equina syndrome produced by protrusion of lumbar disc. BMJ. 1959;2(5164):1434–9.

Fearnside MR, Adams CB. Tumours of the cauda equina. J Neurol Neurosurg Psychiatry. 1978;41:24–31.

Fraser S, Roberts L, Murphy E. Cauda equina syndrome: a literature review of its definition and clinical presentation. Arch Phys Med Rehabil. 2009;90(11):1964-8.

Gleave JRW, Macfarlane R. Cauda equina syndrome: what is the relationship between timing of surgery and outcome? Brit J Neurosurg. 2002;16(4):325–8.

Ahn UM, Ahn NU, Buchowski MS, Garrett ES, Sieber AN, Kostuik JP. Cauda equina syndrome secondary to lumbar disc herniation. A meta-analysis of surgical outcomes. Spine. 2000;25:1515–22.

Gleave JRW, Macfarlane R. Prognosis of recovery of bladder function following lumbar central disc prolapse. Br J Neurosurg. 1990;4:205–10.

O’Laoire SA, Crockard HA, Thomas DG. Prognosis for sphincter recovery after operation for operation for cauda equine compression owing to lumbar disc prolapse. Br Med J. 1981;282:1852–4.

Shapiro S. Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine. 2000;25:348–52.

Todd NV. Cauda equina syndrome: the timing of surgery probably does influence outcome. Br J Neurosurg. 2005;19(4):301–6.

Dining TAR, Schaeffer HR. Discogenic compression of the cauda equina: a surgical emergency. Aust NZ J Surg. 1993;63:927–93.

Lee GY, Lee JW, Choi HS, Oh KJ, Kang HS. A new grading system of lumbar central canal stenosis on MRI: an easy and reliable method. Skeletal Radiol. 2011;40(8):1033-9.

Srikandarajah N, Boissaud-Cooke MA, Clark S, Wilby MJ. Does early surgical decompression in cauda equina syndrome improve bladder outcome?. Spine. 2015;40(8):580-3.

Hussain SA, Gullan RW, Chitnavis BP. Cauda equinasyndrome: outcome and implications for management. Brit J Neurosurg. 2003;17(2):164–7.

McCarthy MJH, Aylott CRW, Grevitt MP, Bishop MC, Hegarty J. Cauda equina syndrome: factors affecting long term function and sphincteric outcome. Spine. 2007;32(2):207–16.

Kostuik JP. Medico-legal consequences of cauda equine syndrome: an overview. J Neurosurg Neurosurg Focus. 2004;16:39–41.

DeLong WB, Polissar N, Neradilek B. Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies. J Neurosurg Spine. 2008;8:305–20.

Findlay G, Macfarlane R, McCarthy MJH, DeLong WB, Poilissar NL, Neradilek B. Neurosurgical forum. J Neurosurg Spine. 2009;11:90–2.

Todd NV. Cauda equina syndrome. The timing of surgery probably does influence outcome. Br J Neurosurg. 2005;19:301–6.