Timing of surgical intervention in cauda equina syndrome: a systematic critical review.
OBJECTIVE
Cauda equina syndrome (CES) is a rare but important neurosurgical emergency. Despite being a recognized clinical entity since 1934, there remains significant uncertainty in the literature regarding the urgency for surgical intervention. The past decade has seen the emergence of the much-referred-to 48-hour limit as a possible window of safety. The ramifications of this time point are significant for early patients who may subsequently have urgent treatment delayed, and for litigation cases, after which adverse decisions are more likely to occur.


METHODS
A systematic principally qualitative review of the animal and human clinical literature is presented, examining the evidence for urgent surgical decompression in CES and the much-quoted 48-hour rule.


RESULTS
There is significant discordance in the literature regarding whether emergency surgery improves outcomes; however, a growing consensus is the acknowledgment that biologic systems deteriorate in a continuous rather than stepwise manner. Level of neurological dysfunction at surgery (incomplete CES vs. CES with retention) is probably the most significant determinant of prognosis. Onset and duration of symptoms also are likely to have an impact, if not on overall outcome then at least on duration of neurological recovery.


CONCLUSIONS
There is no strong basis to support 48 hours as a blanket safe time point to delay surgery. Both early and delayed surgery may result in improved neurological outcomes. However, it is likely that the earlier the surgical intervention, the more beneficial the effects for compressed nerves, especially with acute neurological compromise.
Macquarie Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia; School of Medicine, University of New England, Armidale, New South Wales, Australia. Electronic address: amtchau@gmail.com.
Anthony Minh Tien
AM
Chau
School of Medicine, University of New England, Armidale, New South Wales, Australia; Department of Orthopaedics, Liverpool Hospital, Sydney, New South Wales, Australia.
Lileane Liang
LL
Xu
School of Medicine, University of New England, Armidale, New South Wales, Australia.
Nicholas Robert
NR
Pelzer
Macquarie Neurosurgery, Australian School of Advanced Medicine, Macquarie University, Sydney, New South Wales, Australia; School of Medicine, University of New England, Armidale, New South Wales, Australia.
Cristian
C
Gragnaniello
D000208:Acute Disease; D019299:Decompression, Surgical / Q000592:standards*; D004632:Emergency Medical Services / Q000592:standards*; D019317:Evidence-Based Medicine; D006801:Humans; D011128:Polyradiculopathy / Q000601:surgery*; D061665:Time-to-Treatment / Q000592:standards*
Cauda equina; Evidence-based medicine; Polyradiculopathy; Surgical decompression