Lumbar microdiscectomy for cauda equina syndrome
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Lumbar disc prolapse is a common condition. Cauda equina syndrome is a rare complication of disc prolapse and occurs in around 1.8 per million people. It may present with back pain and/or sciatic pain, bladder or bowel dysfunction, perineal or saddle anaesthesia, and unilateral or bilateral lower limb radiculopathy. It can affect patients of any age but is more common in patients with disc degeneration
It can be divided into CES with retention (CES-R) where there is painless urinary retention, or CES incomplete (CES-I) where there is alteration of normal bladder and bowel function. Both conditions should be investigated and treated as an emergency to prevent long-term sequelae and disability with persistent bladder and bowel dysfunction. It is a different condition to those uncommon elderly patients who have critical spinal stenosis and may have intermittent perineal numbness which comes on at the same time as lower limb claudication symptoms and resolves with sitting.
There has been debate over the years of the critical time to surgery, with this varying from 6 hrs up to 48hrs. The British Association of Spine Surgeons (BASS) and the Society of British Neurological Surgeons (SBNS) published recommendations in Dec 2018 which suggest operating at the earliest safe opportunity. This depends on local expertise, the available resources, and the duration of symptoms.
This feature discusses the features of cauda equina syndrome and how to manage this. It is an important aspect of spinal pathology to be familiar with if you are involved with any aspect of emergency care, spinal or orthopaedic patients.
Author:Mr Stephen Morris FRCS (Tr & Orth)
Institution: The Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK
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Question 1 of 14
Which one of the following options most accurately describes the potential symptoms associated with a Cauda equina syndrome ?CorrectIncorrect
Question 2 of 14
Which one of the following combinations describes the accepted terms when talking about types of cauda equina syndrome?CorrectIncorrect
Question 3 of 14
Which one of the following is the preferred method of confirming cauda equina compression?CorrectIncorrect
Question 4 of 14
Which one of the following options describes the investigation recommendation in the UK for a patient suspected of having cauda equina syndrome?CorrectIncorrect
Question 5 of 14
Prior to commencing microdiscectomy for cauda equina syndrome, which one of the following is not required?CorrectIncorrect
Question 6 of 14
Which one of the following is true when positioning a patient for microdiscectomy?CorrectIncorrect
Question 7 of 14
Which of the following statements are true regarding surface anatomy of the lumbar spine?CorrectIncorrect
Question 8 of 14
Which one of the following statements about the incision for a microdiscectomy is correct?CorrectIncorrect
Question 9 of 14
If you perform only one intra-operative level check, at which one point during the operation should it be performed?CorrectIncorrect
Question 10 of 14
A level check for lumbar microdiscectomy is usually performed using which one of the following methods?CorrectIncorrect
Question 11 of 14
When performing a medial undercutting facetectomy as part of a lumbar decompression which one of the following describes how much of the facet joint can be removed before it becomes potentially unstable?CorrectIncorrect
Question 12 of 14
To expose the disc herniation, the transiting nerve root is retracted which one of the following ways ?CorrectIncorrect
Question 13 of 14
Which one of the annotations shows the disc in this intra-operative image?CorrectIncorrect
Question 14 of 14
Which of the following answers describes most accurately the potential requirements of patients with treated cauda equina syndrome post-operatively?CorrectIncorrect