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A 51-year-old male with a pacemaker reports difficulty with urination and numbness in his bilateral buttock. His symptoms began 12 hours ago. What is the next most appropriate step in management?
MRI of the lumbar spine
CT myelogram of the lumbar spine
Epidural steroid injection
Emergent lumbar decompression
High dose methylprednisone
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This patient has classic symptoms of Cauda Equina Syndrome (CES). The most important next step is identifying a source of compression in the lumbar spine. The study of choice is an MRI, however in patient who cannot have an MRI such as those with pacemakers, a CT myelogram should be performed.
Cauda equina syndrome has been described as a complex of low back pain, bilateral or unilateral sciatica, saddle anesthesia, and motor weakness that can progress to paraplegia and permanent bowel/bladder dysfunction. Cauda equina is an ABSOLUTE indication for surgical treatment of lumbar disc disease. Historically the recommendation was to proceed with surgical decompression within six hours, however new data supports surgery within 48 hours.
Kostuik et al. compared patient treated with surgery at 1.1 days compared to those treated at 3.3 days and found no correlation of these times with return of function. Therefore, they feel even though early surgery should be performed, decompression does not have to be performed in less than six hours.
Ahn et al, in a meta study of 322 patients, found significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.
Answer 1: MRI of the lumbar spine would not be possible due to pacemaker.
Answer 3: Epidural steroid injection would not be indicated.
Answer 4: Ultimately this patient will require an emergent lumbar decompression, but the source of compression must be identified first.
Answer 4: High dose methylprednisone is only indicated in spinal cord injuries that present within 8 hours of presentation.
Kostuik JP, Harrington I, Alexander D, Rand W, Evans D.
J Bone Joint Surg Am. 1986 Mar;68(3):386-91. PMID: 2936744 (Link to Abstract)
Kostuik, JBJS 1986
Buchner M, Schiltenwolf M
Orthopedics. 2002 Jul;25(7):727-31. PMID: 12138958 (Link to Abstract)
Buchner, ORTHO 2002
Ahn UM, Ahn NU, Buchowski JM, Garrett ES, Sieber AN, Kostuik JP
Spine. 2000 Jun;25(12):1515-22. PMID: 10851100 (Link to Abstract)
Ahn, SPINE 2000
Spector LR, Madigan L, Rhyne A, Darden B 2nd, Kim D.
J Am Acad Orthop Surg. 2008 Aug;16(8):471-9. PMID: 18664636 (Link to Abstract)
Spector, JAAOS 2008
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A 49-year-old male presents with saddle anesthesia, lower extremity weakness, and urinary retention. When must surgical decompression be done to improve bladder and motor recovery?
less than 24 hours after symptom onset
less than 48 hours after symptom onset
less than 60 hours after symptom onset
less than one week after symptom onset
less than two weeks after symptom onset
The cauda equina compression syndrome presents with bilateral buttock and lower extremity pain as well as bowel and/or bladder dysfunction (usually urinary retention), saddle anesthesia, and varying degrees of loss of lower-extremity motor/sensory function. Digital rectal exam and perianal sensation is important for immediate diagnosis. This condition is considered a surgical emergency and immediate MRI and surgery are indicated.
The meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation reviewed 42 studies. Length of time to surgery was broken down into five groups: less than 24 hours, 24-48 hours, 2-10 days, 11 days to 1 month, and more than 1 month. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No significant improvement in surgical outcome was identified with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24-48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Significant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms. The conclusion of the study was a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of symptoms. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.
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