Early intervention in cauda equina syndrome associated with better outcomes: a myth or reality? Insights from the Nationwide Inpatient Sample database (2005-2011).

BACKGROUND CONTEXT: Evidence-based consensus on timing to surgical decompression following symptom onset in patients with cauda equina syndrome (CES) is limited or widely debated.

PURPOSE: This study aimed to investigate whether timing to intervention in the management of patients with CES has an impact on outcomes.

STUDY DESIGN/SETTING: This is a retrospective cohort study.

PATIENT SAMPLE: The patient sample included 4,066 adult patients with CES registered in the Nationwide Inpatient Sample database (2005-2011) and undergoing elective decompression surgery.

OUTCOME MEASURES: The outcome measures are inpatient mortality, unfavorable discharge (discharge to rehabilitation), prolonged length of stay (LOS>75th percentile), and high hospital charges in patients undergoing decompression for CES.

METHODS: The patients were stratified into three categories based on timing to surgical intervention: (1) within 24 hours (n=1,846, 45.6%); (2) between 24 and 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 the clustering of similar outcomes within hospitals was used to examine the association of timing to surgical intervention categories with binary primary end points. For metric end points (charges), we used the ordinary least squares model to test the effect of timing to intervention.

RESULTS: The mean 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 (odds ratio [OR]: 3.61, 95% confidence interval [CI]: 1.32-9.85, p=.012), unfavorable discharge (OR: 2.23, 95% CI: 1.87-2.66, p<.001), prolonged postsurgical LOS (OR: 1.76, 95% CI: 1.44-2.14, p<.001), and high hospital charges (OR:1.92, 95% CI: 1.81-2.05, p<.001) were observed in patients operated on 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<.001), prolonged postsurgical LOS (OR: 1.73, 95% CI: 1.35-2.20, p<.001), and high hospital charges (OR: 1.94, 95% CI: 1.79-2.10, p<.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<.001), prolonged postsurgical LOS (OR: 2.06, 95% CI: 1.53-2.77, p<.001), and high hospital charges (OR: 1.39, 95% CI: 1.15-1.68, p<.001).

CONCLUSIONS: Early 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. The timing of intervention did not seem to matter in traumatic CES as compared with degenerative etiology. Prospective randomized controlled trials may further help elucidate the impact of early intervention on outcomes in patients with CES.