Delayed presentation of cauda equina syndrome secondary to lumbar disc herniation: functional outcomes and health-related quality of life

OBJECTIVE: Cauda equina syndrome (CES) is a feared complication of lumbar disc herniation. It is generally accepted that CES requires decompression within 6 hours of symptom onset, but this time goal is rarely met, and the relative benefit of delayed decompression on functional status and quality of life (QOL) remains unknown. The study objective was to describe the functional status and quality of life outcomes for patients who undergo delayed surgical decompression for CES. METHODS: Patients with CES who underwent decompression of a herniated lumbar disc during a 10-year period were assessed at hospital discharge and at least 4 months after the procedure. Evaluation of functional outcomes was based on a previously validated scale and QOL outcomes on the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire. RESULTS: During the study period, 1100 patients with herniated discs were identified, and 14 underwent surgical decompression for CES. All 14 had had symptoms for more than 38 hours before surgery. Ten patients were available for long-term follow-up. There was a strong correlation between long CES symptom duration and poor functional outcome: of 8 patients with symptoms for less than 10 days before decompression (range, 1.6-7.5 d), all had good functional outcomes. The 2 patients with more prolonged symptoms (10.6 and 14.2 d) had poor outcomes. SF-36 scores demonstrated declines in physical roles (p = 0.03), social function (p = 0.03) and increased pain (p = 0.003) compared with population norms. Correlation between SF-36 domain scores and CES symptom duration failed to achieve statistical significance, perhaps because of small sample size. CONCLUSIONS: Patients who undergo delayed decompression for CES have increased pain and impaired social and physical function. Longer delays correlate with worse functional outcomes. Beyond 24 hours, decompression delay may be associated with a poorer quality of life but, because of the rarity of CES, the sample size in this study was too small to provide definitive conclusions. Since no patients underwent surgery within 38.4 hours of symptoms, it is not possible to comment on the importance of emergent decompression in early presenters.