of Surgical Decompression of Cauda Equina Syndrome by Laminectomy and Discectomy

Background: Cauda equina syndrome (CES) is a relatively uncommon condition typically associated with a large, space occupying lesion within the canal of lumbo-sacral spines. This syndrome is characterized by varying pattern of low back pain, sciatica, lower extremity sensorimotor loss, saddle anaesthesia and bowel and bladder dysfunction. Objective: The objective of this study was to evaluate clinical and functional outcome and operative complications in case of CES who underwent surgical decompression by laminectomy and discectomy. Materials and method: This prospective interventional study was carried out at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) and different private hospitals in Dhaka from January 2017 to December 2019. Patients were selected on the basis of history, clinical examinations and Magnetic Resonance Imaging (MRI) findings. Patients with fracture and compression due to other than disc prolapse were excluded from the study. Results: Out of 23 patients, 18 patients (78%) were male and 5 patients (22%) were female, age ranged from 20-60 years, with the average age 37.5 years. Twenty one patients (91%) had single level and 2 patients (9%) had two level disc herniation. The mean follow up duration was 9 months (range 6-12 months). Patients were evaluated with respect to age, time to surgery and scoring system for CES before and after operation. Those who were treated within 48 hours and those after 48 hours showed significant difference in outcome (p <0.05). Complete recovery was documented in 12 patients (52%). There was infection in 01 case (4%), 03 patient (13%) had persistent low back pain, 02 patients (9%) had sciatica, 01 patients (4%) had bowel and bladder dysfunction and 01 patients (4%) had saddle anaesthesia in delayed operative group. Evaluation of final outcome was satisfactory in 17 patients (74%). Conclusion: Laminectomy and discectomy is an effective, safe and acceptable modality of treatment in CES.


Introduction
Cauda equina syndrome (CES) is a relatively uncommon condition typically associated with a large, space occupying lesion within the canal of lumbo-sacral spines.This syndrome is characterized by varying pattern of low back pain, sciatica, lower extremity sensorimotor loss, saddle anaesthesia and bowel and bladder dysfunctionand loss of tendon reflexes. 1It is an orthopaedic emergency condition.Imaging of Cauda equina and decompression is urgently needed if large central disc is revealed.Decompression by laminectomy and discectomy provides full relief of pressure on cauda equina. 2 The objective of this study was to evaluate clinical and functional outcome and operative complications in cases of CES who underwent surgical decompression by laminectomy and discectomy.

Materials and method
This prospective interventional study was carried out at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) and different private hospitals in Dhaka from January 2017 to December 2019.Total number of patients were 23 who underwent surgical decompression by laminectomy and discectomy with a follow up period of six months to one year.Patients were selected on the basis of history, clinical examinations and MRI findings.Patients with fracture, compression due to other than disc prolapse were excluded from the study.
Patients were evaluated with respect to age, time of surgery, and cauda equina syndrome score before and after operation.Decompression by laminectomy and discectomy were performed in all the cases.Approach was posterior midline.Intravenous antibiotic was given per and postoperatively for three days.Third generation cephalosporin was given.Scoring System for Cauda Equina Syndrome (SSCES) was applied. 3tatistical analysis was made using a computer software programme, the Statistical Package for the Social Sciences (SPSS).A value of p <0.05 was accepted to indicate statistical significance.
The mean preoperative scoring system for cauda equina syndrome (SSCES) was 12.7±2.8(7-16) and the mean final follow up score was 7.6±3.4(2-13) at 12 month.The 17 patients (74%) that had a mean preoperative SSCES of 13 or below, showed satisfactory clinical results with a mean SSCES of 7.9±5.1 (5-9) on the final follow up at 12 month.Six patients (26%) with a mean preoperative SSCES of 14 or above showed unsatisfactory clinical results with a mean SSCES of 14.9±1.9(7-13) at final follow up at 12 month.

Discussion
It is incorrect to believe that there is a clear clinical picture of CES.There is no combination of clinical symptoms and signs that reliably predict CES. 1 Surgical decompression should be performed if the patient is medically stable and able to undergo the procedure. 2,4,5e timing of surgical decompression is controversial with immediate, early and late showing varying results. 2 In acute CES, patients need to be operated within 6 hours 6 , but several authors have argued over the clarity of the data supporting this practice. 3,4,7Hussain et al. 2 reported no differences at 16 months follow up among patients who underwent surgery within 24 hours.
We found better results in those who were operated within 48 hours than those who were operated later.In this series, young patients had better results than the older group.Single level disc prolapse showed better results than multilevel disc prolapse.

Conclusion
With the discussion mentioned above it was concluded that surgical decompression by laminectomy and discectomy is an effective, safe and acceptable modality of treatment of CES.It relieves the mechanical pressure over cauda equina and improves the symptoms and quality of life of the patients.