Early intervention in cauda equina syndrome associated with better outcomes: a myth or reality? insights from the nationwide inpatient sample database 2005-2011

Publication date: Available online 26 April 2017
Source:The Spine Journal
Author(s): Jai Deep Thakur, Christopher Storey, Piyush Kalakoti, Osama Ahmed, Rimal H. Dossani, Richard P. Menger, Kanika Sharma, Hai Sun, Anil Nanda
Background ContextEvidence-based consensus on timing to surgical decompression following symptom onset in patients with cauda equine syndrome (CES) is limited or widely debated.PurposeTo investigate timing to intervention in management of patients with CES impacts outcomes.Study Design/SettingRetrospective cohort study.Patient Sample4,066 adult patients with CES registered in the Nationwide Inpatient Sample (NIS) database (2005-2011) and undergoing elective decompression surgery.Outcome MeasuresInpatient mortality, unfavorable discharge (discharge to rehabilitation), prolonged length of stay (LOS>75^th percentile) and high hospital charges in patients undergoing decompression for CES.MethodsPatients were stratified into 3 categories based on timing to surgical intervention: (1) within 24 hours (n=1,846; 45.6%); (2) between 24-48 hours (n=1,080; 26.6%) and (3) beyond 48 hours (n=1,130; 27.8%). Multivariable logistic regression fitted with generalized estimating equations using the sandwich variance-covariance matrix estimator to account for clustering of similar outcomes within hospitals was used to examine the association of timing to surgical intervention categories with binary primary endpoints. For metric endpoint (charges), we used the ordinary least squares model to test the effect of timing to intervention.ResultsMean age of the cohort was 50.19 ± 17.55 years and 41% were female. In comparison to patients operated within 24 hours, increased likelihood of inpatient mortality (OR: 3.61; 95% CI: 1.32–9.85; p=0.012), unfavorable discharge (OR: 2.23; 95% CI: 1.87–2.66; p<0.001), prolonged post-surgical LOS (OR: 1.76; 95% CI: 1.44–2.14; p<0.001) and high-hospital charges (OR:1.92; 95% CI: 1.81-2.05;p<0.001) was observed in patients operated over 48 hours since admission. Likewise, patients with incomplete CES with intervention beyond 48 hours had higher odds for unfavorable discharge (OR: 2.51; 95% CI: 1.99–3.17; p<0.001), prolonged post-surgical LOS (OR: 1.73; 95% CI: 1.35–2.20; p<0.001), and high-charges (OR: 1.94; 95% CI: 1.79–2.10; p<0.001). Likewise, patients with complete CES with interventions beyond 48 hours had higher odds for unfavorable discharge (OR: 1.86; 95% CI: 1.41–2.45; p<0.001), prolonged post-surgical LOS (OR: 2.06; 95% CI: 1.53–2.77; p<0.001) and high charges (OR: 1.39; 95% CI: 1.15–1.68; p<0.001).ConclusionsEarly intervention in CES, regardless of the subtype (complete or incomplete) has higher likelihood of improved inpatient outcomes. The odds of getting better were higher however with incomplete CES. Timing of intervention did not seem to matter in traumatic CES as compared to degenerative etiology. Prospective randomized-controlled trials may further help elucidate the impact of early intervention on outcomes in patients with CES.



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