Asian Journal of Orthopaedic Research

4(1): 17-29, 2020; Article no.AJORR.59932

Evolution of the Surgical Management of Cauda

Equina Syndrome
B. S. Kashif Malik1*, B. S. Vamsi Reddy2, B. S. Akul Munjal3
and Anterpreet Dua1
1
Department of Anesthesia and Perioperative Medicine, Medical College of Georgia, Augusta,
Georgia, United States of America.
2
Department of Neurosurgery, Medical College of Georgia, Augusta, Georgia,
United States of America.
3
Department of Orthopedic Surgery, Medical College of Georgia, Augusta, Georgia,
United States of America.

Authors’ contributions

This work was carried out in collaboration among all authors. All authors were involved in the design
and conception of this manuscript.

Article Information

Editor(s):
(1) Dr. Ikem, Innocent Chiedu, Obafemi Awolowo University, Nigeria.
(2) Dr. Parth Trivedi, C.M. Patel College of Physiotherapy, India.
Reviewers:
(1) Khelifa Adel, Bab El Oued University Hospital and Algiers University, Algeria.
(2) Parisa Azimi, Shahid Beheshti University of Medical Sciences, Iran.
(3) Suresh Sivadasan Pillai, Baby Memorial Hospital, India.
Complete Peer review History: http://www.sdiarticle4.com/review-history/59932

Received 02 June 2020

Accepted 07 August 2020
Review Article
Published 11 August 2020

ABSTRACT

Cauda equina syndrome arises secondary to lumbosacral nerve root entrapment, mostly a result of
lumbar disc herniation. Clinically, it manifests as sciatica, saddle anesthesia, lower limb weakness,
and bowel/bladder dysfunction. Surgical management has developed significantly over the past
decades. This literature review aims to shed light on surgical interventions for this condition.
Results from 22 original articles have been summarized. Most authors advocate for emergency
surgical intervention in all cases. Surgery is performed via an open or endoscopic technique.
Open surgery involves lumbar discectomy with laminectomy. It can be carried out with a
conventional operative microscope. In contrast, endoscopic discectomy utilizes a minimally
invasive incision that minimizes blood loss and the duration of hospital stay. Recent radiologic
advances including intraoperative X-ray fluoroscopy, CT scan and ultrasonography have also
markedly improved surgical outcomes for lumbar discectomy.
_____________________________________________________________________________________________________

*Corresponding author: Email: kmalik@augusta.edu;

 Malik et al.; AJORR, 4(1): 17-29, 2020; Article no.AJORR.59932

Keywords: Cauda equina; management; surgery; evolution.

1. INTRODUCTION Therefore, lumbar decompression via discectomy

is an important intervention for relieving
Cauda equina syndrome, although rare, is lumbosacral nerve root compression. This can be
clinically severe. Cauda equina syndrome substituted by microdiscectomy in which the
derives its name from Latin, with cauda meaning lumbar disc is microsurgically resected through a
“tail” and equina meaning “horse”. The cauda small incision. Also, endoscopic instrumentation
equina of the spine constitutes the lumbar and has revolutionized this surgical technique.
sacrococcygeal nerve roots (L2 to Co1 spinal
nerves) that arises from the terminal spinal cord The discectomy procedure involves targeting the
(L1-L2 in adults and L3 in children). These nerve lamina and carrying out a laminectomy or
fibers can be compressed with trauma laminotomy thus, accessing the protruded disc to
(intervertebral disc herniation) or underlying relieve pressure on the affected nerve root. The
pathologic lesions (e.g. spinal tumors, myelitis, first discectomy operation was performed by F.
lumbar spinal stenosis, etc.) and thus, can Krause (early 1900s) where the surgeon entirely
produce symptomatology, broadly termed as the resected the pathological lesion of the spine with
cauda equina syndrome [1]. the aid of laminectomy followed by a transdural
discectomy. Upon follow-up, the patient showed
Epidemiologic data states the overall incidence complete relief of pain. A few years later, A.
of cauda equina syndrome ranges between 7 Taylor successfully carried out an extradural
and 9 per 100,000/year in the adult working discectomy.
population in the developed world [2,3]. Minimal 1.2 Hemilaminectomy/Laminectomy [11,
data assess age, racial features, and
12]
job/profession as the etiological factors [4].
Several clinical manifestations are a result of this This includes surgical resection of either one or
syndrome including lower limb pain (sciatica), both laminae of the involved vertebrae which
sensorimotor defects, loss of lower limb deep allows surgical decompression of the nerve
tendon reflexes, lower back pain, urinary and/or roots. Such an approach is necessary for cauda
bowel dysfunction, anogenital sensory loss equina syndrome occurring secondary to
(saddle anesthesia), and poor sexual function [5]. posterior lamina trauma etc. Laminectomy or
History and clinical examination followed by laminotomy may be carried out through open or
magnetic resonance imaging (MRI) are used to endoscopic procedures. The first laminectomy
diagnose cauda equina syndrome [6]. Other was performed by W. MacEwen or V. Horsley in
diagnostic evaluations include CT scans or spine the 1880s. However, the first-ever
x-ray/myelograms. Urodynamic studies (residual hemilaminectomy is believed to be carried out by
urine volume) are significantly important in Taylor et al.
monitoring urinary symptoms related to detrusor
hyperactivity or hypoactivity [7]. Management of 1.3 Development of Endoscopic
this neurologic condition has changed Procedures for Discectomy/
tremendously in the past decades. Symptomatic Laminectomy [13,14,15]
relief of pain is brought about with the use of an
extensive steroid or non-steroidal anti- The endoscopic intervention technique has
inflammatory drug (NSAID) therapy. Moreover, potentially changed the scenario of spine surgery
limited evidence suggests an advantageous role by making it as minimally invasive as possible.
of vasodilator drugs (e.g. prostaglandin analogs) Lumbar spine surgery has now become
in the management of pain [8]. On the other convenient with a smaller incision, minimal scar
hand, the surgical intervention aims at managing formation, and shorter duration of hospital stay.
the underlying cause of cauda equina syndrome. The historical invention of an endoscope is
Most of the operative interventions are credited to Philipp Bozzini (in the 19th century).
conducted as follows: In 1973, Kambin et al described the first
percutaneous nucleotomy procedure for cord
1.1 Lumbar Discectomy decompression. In the next decade, the
arthroscopic view of the intervertebral region was
[9,10,11] Most etiological data reveals that first established by Forst et al. Moreover, in the
lumbar disc protrusion is one of the most past 2-3 decades, the intervertebral trans-
common causes of cauda equina syndrome. foraminal approach has been developed to gain

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endoscopic access to a prolapsed disc. operation is a modern closed surgical approach

Neurosurgeons have now combined the for accessing a herniated lumbar disc to allow
microsurgical operative technique with cauda equina decompression. Another technique
endoscopy to achieve a better view of the involves microsurgical sectioning of the dorsal
pathological site. Also, the development of root entry zone of the lumbar spinal segments.
laparoscopic lumbar surgery via the anterior Moreover, a lumboperitoneal shunting procedure
approach has been considered a major can also be conducted in cases of cauda equina
milestone in the era of spine surgery. Presently, syndrome arising from ankylosing spondylitis.
fluoroscopic X-ray techniques are being adopted
intraoperatively to guide a neurosurgeon during Cauda equina syndrome is considered an
lumbar discectomy procedures. emergency requiring a rapid clinical and
radiologic diagnosis as well as an accurately
2. MATERIALS AND METHODS timed surgical intervention. The timing of surgery
in such cases has been given due importance by
This study was designed as a literature review. many neurosurgeons. Kohles, S et al. [38] state
All the articles pertaining to the surgical that decompression carried out within the first 48
management of Cauda Equina Syndrome were hours of emergency admission is likely to be
obtained through search engine sources, helpful in the post-operative recovery phase. On
including PubMed Central (PMC) and Google the other hand, older literature suggests that
Scholar. The following keywords were utilized: there is no statistically significant correlation
Management of Cauda Equina Syndrome; between the timing of surgery and post-operative
Cauda Equina Decompression Surgery; Lumbar patient prognosis. Kostuik, J. P et al. [39]
Discectomy; Open and Endoscopic Lumbar reviewed 31 cauda equina syndrome cases
Discectomy; Lumbar Laminectomy. Thirty-two retrospectively. The authors concluded that there
articles were selected in the first phase. The was no major difference between the operative
inclusion criterion was to include all those clinical outcomes of the cases intervened within 6-48
studies, retrospective studies, and case hours and those operated between 1-5 days of
series/case reports that encompassed results onset of symptoms. In short, the timing of
related to the surgical management of cauda decompression surgery in cases of cauda equina
equina syndrome (arising from lumbar disc syndrome remains controversial.
herniation) in the past two decades i.e. from
2000-onwards. All those articles which discussed Timely management of cauda equina syndrome
any systematic review or meta-analysis related to can be achieved through open or closed
the subject were excluded from the literature procedures. Limited research material is
review. After exclusion, a total of 22 articles were available which draws a comparative analysis
incorporated into the final review. They were between the two techniques. Phan, K., Xu, J et
thoroughly studied for their clinical/surgical al. [40] have compared the efficacy of three
output and their result summaries were different modalities of lumbar spine
organized accordingly. decompression surgery i.e. full endoscopic,
micro-endoscopic, and open discectomy
3. RESULTS operations. By analyzing the patient outcome
with the help of the Visual Analog Scale and
Abstracts from all of the selected articles were Oswestry Disability Index, there was no major
thoroughly studied and were further categorized discrepancy noted between the efficacies of
according to the intervention modality discussed open discectomy and endoscopic procedures. A
by the authors. The main findings from the shorter duration of operative surgery was noted
literature review are explained in the Tables 1-3. in the case of the endoscopic procedure.
Moreover, average blood loss was found to be
4. DISCUSSION comparatively lower in the endoscopic
approaches. However, no considerable
This study has reviewed the major surgical difference was observed in the case of the
intervention methods utilized for the efficacious incidence of surgical complications (dural tears,
management of cauda equina syndrome. wound infections, etc.). In a similar sense, other
Operative techniques include open and authors have also concluded that endoscopic
endoscopic procedures. Open surgery consists discectomy is equally efficacious for the
of lumbar discectomy combined with management of herniated lumbar disc and cauda
laminotomy/laminectomy or hemilaminectomy, equina syndrome. However, there is still need for
mostly performed microsurgically. Endoscopic further research in this area [41,42].

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Table 1. Surgical outcomes from open via discectomy and laminectomy

Sr. Title of the article Authors Journal of Year of Main FINDINGS

no. publication publication
1. Lumbar herniated Chang, H. S., Surgical Neurology 2000 This study included 144 cases of lumbar disc herniation out of
disc presenting with Nakagawa, H which only 4 had cauda equina syndrome. These 4 cases were
cauda equina et al regularly followed in the post-operative months. Long term follow-
syndrome: Long- up revealed a significant recovery in the urinary disturbance.
term follow-up of four Therefore, the authors have stressed not to rely upon short-term
cases [16] post-surgical surveillance for improvement in bladder function.
2. Cauda Equina Buchner, M. & Orthopedics 2002 A total of 22 patients were treated with discectomy for their
Syndrome Caused Schiltenwolf, cauda equina syndrome secondary to lumbar disc prolapse.
by Intervertebral M Seventeen patients showed a markedly improved bladder function.
Lumbar Disc Four continued to have stress incontinence whereas 1 case even
Prolapse: Mid-Term needed catheterization. Similarly, marked rehabilitation of
Results of 22 sensorimotor function was observed upon follow-up. No significant
Patients and correlation was observed between the period from the appearance
Literature Review of symptoms to surgical intervention and postoperative outcome.
[17]
3. Cauda equina Hussain, S. British Journal of 2003 In this retrospective study, a total of 20 patients were included who
syndrome: outcome A., Gullan, R. Neurosurgery had been diagnosed with cauda equina syndrome through MRI
and implications for W et al or CT scan. All cases were operated through laminectomy
management [18] combined with discectomy. Emergencydecompression was
performed in nine cases (<5 hours). The remaining 11 patients
were also operated within 24 hours of presentation. A markedly
improved urinary function and better life quality were observed in
both the groups postoperatively. Moreover, no significant
differences were seen for patient prognosis at follow-up analysis.
4. Cauda equina Qureshi, A. & European Spine 2007 This study involved a review of 33 cases of cauda equina
syndrome treated by Sell, P Journal syndrome (due to lumbardisc herniation) that were treated
surgical surgically. Operative techniques included microdiscectomy or
decompression: the laminectomy/hemilaminectomy combined with a discectomy
influence of timing on procedure. Twelve patients were operated within 48 hours of the
surgical outcome appearance of first symptoms while 7 underwent surgery within
[19] the first 24 hours. No significant correlation was established

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Sr. Title of the article Authors Journal of Year of Main FINDINGS

no. publication publication
between the timing of operation (>24 hours; 24-48 hours; >48
hours) and surgical outcome. However, cases without urinary
dysfunction preoperatively had a better prognosis than those who
had urinary dysfunction.
5. Cauda Equina Olivero, W. Journal of Spinal 2009 This study reviewed statistics from 31 patients of cauda equina
Syndrome (CES) C., Wang, H Disorders & syndrome associated with lumbar disc herniation. Twenty-eight
From Lumbar Disc et al Techniques patients had been catheterized due to urinary dysfunction
Herniations [20] secondary to cauda equina compression. A total of 6 cases
underwent decompression surgery within the first 24 hours, 8
cases were operated between24 to 48 hours and the remaining
17 underwent surgery after2 days. All of the cases were treated
with either laminotomy/laminectomy, following which 27 patients
regained urinary continence. Moreover, no statistically significant
correlation was found between the timing of surgical intervention
and surgical outcome.
6. Surgical treatment of Quraishi, N. European Spine 2013 Twenty patients received cauda equina decompression surgery
cauda equina A., Journal for metastatic lesions present in the lumbosacral region.
compression as a Giannoulis, K. Fourteen cases presented with complaints of pain and
result of metastatic E et al neurological deficit due to underlying cauda equina syndrome.
tumors of the Moreover, 3 patients had developed urinary dysfunction. Spinal
lumbosacral junction decompression was performed in all of the cases following which,
and sacrum [21] 19/20 cases either improved or stabilized. Moreover, urinary
function remained normal in 19 cases post-operatively. A
complication rate of 30% was observed at follow-up.
7. Does Early Surgical Srikandarajah, Spine 2015 Data were collected from 200 individuals who were operated on for
Decompression in N., Boissaud- cauda equina decompression. The surgeons categorized these
Cauda Equina Cooke, M. A. CES cases with respect to their presenting urinary complaints i.e.
Syndrome Improve et al CESI (incomplete) – 139 cases and CESR (with urinary
Bladder Outcome? retention) – 61 cases. For those cases of CESI that were
[22] operated within 48 hours (64), approximately 84% had improved
bladder function. On the contrary, only 44% of those cases
operated after 48 hours of diagnosis (75) showed a remarkably
improved urinary function. However, operation timing showed no

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Sr. Title of the article Authors Journal of Year of Main FINDINGS

no. publication publication
correlation with improved bladder function in 35 cases of CESR.
8. Urgent discectomy: Schebesch, K. Surgical Neurology 2016 Emergency microsurgical discectomy was performed in at least
Clinical features and M., Albert, R International 72 patients out of a total of 526 lumbar disc herniation cases.
neurological et al Important clinical presentations were of cauda equina syndrome
outcome [23] i.e. radicular pain, sensorimotor deficit, sensory loss in the
anogenital region, and sphincter dysfunction. The surgical
intervention resulted in the marked recovery of sensory and motor
functions as interpreted at regular follow-ups.
9. A Successful Mugge, L., Cureus 2019 This case report describes a case of cauda equina syndrome
Outcome Despite Caras, A et al secondary to lumbar disc protrusion. A 19-year old type 1
Delayed Intervention diabetic patient presented with symptoms of foot drop, anogenital
for Cauda Equina sensory loss, and severe lower backache. Spine MRI revealed L3-
Syndrome in a L4 disc herniation and associated cord compression. Cauda
Young Patient with a equina decompression surgery was carried out microsurgically.
Posterior Epidural Laminectomy (done bilaterally at L3 and partly at L4) was
Disc Extrusion [24] performed which revealed an underlying protruded lumbar disc.
Post-surgically, the patient showed a prompt recovery of CES
symptoms.

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Table 2. Surgical Outcomes from Endoscopic Lumbar Decompression

Sr. Title of the article Authors Journal of publication Year of Main Findings
No. Publication
Endoscopic Procedure:
1. Endoscopic Spinal Surgery for Shim, Y. B., Journal of Korean 2007 The researchers analyzed records of 71 cases of
Herniated Lumbar Discs [25] Lee, N. Y et Neurosurgical Society lumbar disc herniation that had been operated via
al 73endoscopic procedures. Up to 80% of cases had a
significant recovery post-surgically. One of these
cases had to undergo a secondary open
discectomy and laminectomy procedure. For those
with a poor outcome (5), two patients were re-
operated which resulted in an improved result. There
were two instances of discitis seen that were
managed either conservatively or with lumbar fusion
surgery.
2. Complications of Endoscopic Sairyo, K., Minimally Invasive 2010 In this study, a total of 138 cases underwent
Lumbar Decompression Sakai, T, et Neurosurgery endoscopic decompression surgery. The authors
Surgery [26] al. monitored the operative complications. It was
observed that overall 11 patients (8.6%) developed
surgery-related complications including dural tears,
hematoma formation, and neurological deficits.
3. Endoscopic lumbar Jhala, A., & Indian Journal of 2010 In this study, 100 individuals underwent micro-
discectomy: Experience of Mistry, M Orthopaedics endoscopic discectomy. All patients were checked
first 100 cases [27] with a pre-operative MRI and 11% also had a post-
operative MRI. The mean operation duration was
recorded at 70 minutes while the average loss of
blood was about 20-30 ml. Post-surgical MRI (11
patients) revealed a total spinal decompression.
Almost 90% of the cases showed a good prognosis.
Only 4 patients had a recurrence of pain or other
symptoms.
4. Revisional Percutaneous Full Shin, K. H., Asian Spine Journal 2011 In this study, 41 patients were re-operated for
Endoscopic Disc Surgery for Chang, H. G recurrent lumbar disc herniation, severe lumbar spinal
Recurrent Herniation of et al nerve compression, or intense refractory spinal pain.

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Sr. Title of the article Authors Journal of publication Year of Main Findings
No. Publication
Previous Open Lumbar All the cases underwent percutaneous endoscopic
Discectomy [28] lumbar discectomy. Post-operatively, marked
improvement was seen in a majority of patients by
using the Visual Analog Scale. Two cases had a
recurrence of herniation while 4 developed other
complications.
5. Treatment of cauda equina Li, X., Dou, Acta Neurologica 2016 In this study, 16 patients diagnosed with cauda
syndrome caused by lumbar Q et al Belgica equina syndrome secondary to lumbar disc
disc herniation with herniation were included. Percutaneous
percutaneous endoscopic endoscopic discectomy was performed in all of the
lumbar discectomy [29] patients. Macnab criterion and visual analog scale
were used for evaluation of patient prognosis. Initial
complaints of leg pain and backache were remarkably
resolved following the surgical intervention. A few
complications were seen in the form of motor
weakness.
6. Five-year outcomes and Ahn, Y., Lee, Medicine (Baltimore) 2018 A total of 204 patients who underwent transforaminal
predictive factors of U et al endoscopic lumbar discectomy were
transforaminal full-endoscopic retrospectively reviewed and the patient prognosis
lumbar discectomy [30] was assessed with the aid of a visual analog scale
and Oswestry Disability Index. All of the patient
parameters improved substantially following the
surgical intervention. Overall satisfaction with the
procedure was seen in 94% cases.
7. Full-endoscopic discectomy Hua, W., Tu, Medicine (Baltimore) 2018 In this study, 84 subjects were included who had been
via the interlaminar approach J et al operated for endoscopic lumbosacral discectomy.
for disc herniation at L4-L5 The postoperative outcome was evaluated via the
and L5-S1 An observational Visual Analog Scale and Oswestry Disability
study [31] Index. The patient scores got significantly better at
follow-up analysis. The main surgical complications
were epineurium injury or cauda equina syndrome.
Studies comparing Open and Endoscopic Surgical Approaches:
8. Percutaneous Endoscopic Jin-Sung Pain Physician 2016 This study included 43 cases. Twenty patients

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Sr. Title of the article Authors Journal of publication Year of Main Findings
No. Publication
Lumbar Discectomy as Kim underwent percutaneous endoscopic lumbar
an Alternative to Open discectomy whereas 23 were treated with
Lumbar Microdiscectomy openmicrodiscectomy. Both treatment groups
for Large Lumbar Disc revealed a marked improvement with respect to leg
Herniation [32] and back pain post-operatively. Moreover, the
endoscopy group had a much better improvement in
backache comparatively while the overall patient
satisfaction rate was also greater in the endoscopy
group. The average operation time and duration of
hospital stay was shorter for those treated
endoscopically. There were no surgery-related
complications seen in both groups.
9. Clinical comparison of Kim, S. K., Journal of Orthopaedic 2018 This study identified 141 patients that underwent
unilateral bi-portal endoscopic Kang, S. S Surgery and Research lumbosacral discectomy for their degenerative disc
technique versus open et al disease. Sixty patients were managed with an
microdiscectomy for single- endoscopic approach while the remaining 81 cases
level lumbar discectomy: a underwent open microsurgical operation. The visual
multicenter, retrospective analog scale, Oswestry Disability Index, and
analysis [33] Macnab criterion were used to assess the patient
prognosis. Those individuals undergoing endoscopic
treatment had a comparatively lesser blood loss than
the patients undergoing open surgery, while the
hospital stay was also found to be much shorter in the
former. However, the total length of surgery was
significantly greater for those in the endoscopy group.

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Table 3. Miscellaneous Surgical Techniques for Cauda Equina Associated Sequalae

Sr. Title of the Authors Journal of Year of Main Findings

No. article publication Publication
1. Dorsal root entry Sampson, J. Journal of 1995 This was a retrospective analysis of 39 patients who were surgically treated
zone lesions for H., Cashman, Neurosurgery with dorsal root entry lesioning following traumatic damage to the conus
intractable pain R. E et al medullaris / cauda equina region. Post-surgical follow-up analysis showed
after trauma to the that >50% had their pain resolved. The operative outcome was better in those
conus medullaris cases who presented with only a partial neurological defect. Post-operative
and cauda equine complications (~20%) were seen in the form of motor weakness, CSF
[34] leakage, and urinary dysfunction.
2. Microsurgical M. Sindoua, P. Pain 2001 A total of 44 patients were included in this study all suffering from severe
DREZotomy for Mertens et al neuropathic pain secondary to a spine injury. Four of these patients had
pain due to spinal developed serious cauda equina damage. Dorsal root entry zone
cord and/or cauda microsurgery or
equina injuries: DREZotomy was carried out in all of the patients to relieve their pain. Almost
long-term results 60% of the cases received long term pain relief post-operatively. Some major
in a series of 44 complications included CSF leakage, infection, and hematoma. No deaths
patients [35] were seen.
3. The Utility of Friedman, J. Spine 2003 A total of nine patients were included in this study that had been diagnosed
Intraoperative A., Wetjen, N. with a cauda equina tumor via an MRI scan. Also, 4 cases were examined
Ultrasound for M et al through transdural ultrasound intraoperatively. Among 3 of these cases,
Tumors of the intraoperative US showed significant migration of tumor mass (as far as one
Cauda Equina complete vertebral segment) when compared with pre-operative MRI findings.
[36] Hence, this allowed the neurosurgeons to undertake essential changes in the
surgical approach for laminectomy.
4. Cauda Equina Ea, H. K., Spine 2010 The researchers included 9 cases of ankylosing spondylitis in this study out
Syndrome in Lioté, F et al of which 8 had developed cauda equina syndrome. Initially, major
Ankylosing symptoms included urinary dysfunction, sensory loss, and lower backache.
Spondylitis: Later, a few patients also developed motor dysfunction and loss of sphincter
Successful control. Pre-operative MRI revealed dural sac dilatation in all of the 9 cases.
Treatment With Lumbo-peritoneal shunting was performed in 5 patients and was
Lumboperitoneal associated with subsequent recovery of sensory function, sphincteric
Shunting [37] disturbance, and pain symptoms.

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Modern intraoperative imaging technology has 2. Hoeritzauer I, Wood M, Copley PC,

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All data pertaining to this research article are medical journal. 2009;122(10):1214-1222.
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It is not applicable. 10. Herkowitz HN (Ed.). The lumbar spine.
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ETHICAL APPROVAL
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Clinical Orthopaedics and Related
It is not applicable.
Research®. 2015;473(6):1885-1895.
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COMPETING INTERESTS decompressive laminotomy. A new
endoscopic approach for spinal stenosis
Authors have declared that no competing decompression. The Spine Journal.
interests exist. 2015;15(10):2282-2289.
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