Urgent discectomy: Clinical features and neurological outcome.

BACKGROUND: To evaluate the clinical features and outcome of patients with progressive neurological deficits due to disc herniation who were treated surgically within 24 h.
METHODS: We conducted a retrospective analysis of consecutive patients who were admitted between 2004 and 2013 via the Emergency Department. Records were screened for presenting symptoms, neurological status at admission, discharge, and 6-week follow-up.
RESULTS: About 72 of 526 patients underwent surgery within 24 h. Magnetic resonance imaging showed lumbar disc herniation in 72 patients. The most common presenting symptoms included radiculopathy (n = 69), the Lasègue sign (n = 60), sensory deficits (n = 57), or motor deficits (n = 47). In addition, 11 patients experienced perineal numbness and 12 had bowel and bladder dysfunction. At discharge, motor and sensory deficits and bowel and bladder dysfunction had improved significantly (P < 0.001, P = 0.029, and P = 0.015, respectively).
CONCLUSION: Motor deficits, sensory deficits, and cauda equina dysfunction were significantly improved immediately after urgent surgery. After 6 weeks, motor and sensory deficits were also significantly improved compared to the neurological status at discharge. Thus, we advocate immediate surgery of disc herniation in patients with acute onset of motor deficits, perineal numbness, or bladder or bowel dysfunction indicative of cauda equina syndrome.

BACKGROUND

Lumbar disc herniations may be associated with sensory and motor deficits and, less frequently, with the cauda equina syndrome, including perineal numbness and/or bladder and/or bowel dysfunction.[157] This study describes the clinical features and outcomes of patients who were evolving acute cauda equina syndromes characterized by the sudden onset of sensory, motor deficits, sphincteric dysfunction warranting surgical treatment within 24 h.

METHODS

We retrospectively reviewed the records of 526 patients with disc herniations and isolated 72 presenting with magnetic resonance (MR)-documented acute lumbar disc herniations contributing to severe radicular pain and cauda equina syndromes evolving over a 24 h period. Records were analyzed for multiple demographic criteria; age, sex, presenting symptoms/signs, neurological deficits, MR (75 patients/CT in 5 [pacemakers]), surgical procedures, and outcomes at 6 postoperative weeks [Table 1]. Lumbar discs were removed utilizing microsurgical resection (e.g., translaminar approach). The study was approved by the Local Ethics Committee (14-101-0086).

Table 1

Baseline data and clinical presentation

Indications for urgent surgery

About fifty-seven patients (79%) with acute onset of sensory deficits, 47 patients (65%) with acute onset of motor deficits, and 12 patients (17%) with cauda equina syndromes required emergency surgery within 24 h. The mean surgery time was 90 min (28–180 min).

Statistical analysis

All data are expressed as the mean value plus the standard error of the mean. Different groups were compared with the rank sum test (Mann–Whitney Test) (Sigma Stat Version 3.0, SPSS, Inc., Chicago, IL, USA). Correlations between data groups were evaluated by means of the Spearman rank analysis, and the level of significance was set at P < 0.05.

RESULTS

Morbidity

Perioperative complications occurred in four patients (6%) The surgical complications were dural tear in one patient, one subcutaneous seroma, one deep vein thrombosis, and one patient with retained disc prolapse due to the failure of removal during the first surgery. No patient required intraoperative or postoperative transfusions.

Outcome

Motor deficits, sensory deficits, and bladder and/or bowel dysfunction improved significantly (P < 0.001, P = 0.029, and P = 0.015, respectively), immediately, postoperatively. Motor deficits and sensory deficits further improved during follow-up, but bowel and bladder dysfunction plateaued. Alternatively, perineal numbness did not improve significantly within 6 weeks [Table 2].

Table 2

Postoperative outcome

Complications

During the average 6 weeks follow-up interval, one patient suffered from new radicular pain due to recurrent disc herniation. This patient required reoperation.

DISCUSSION

We analyzed 72 patients who presented with the acute onset of neurological deficits due to lumbar nerve root or cauda equina syndrome attributed to acute soft disc herniations that necessitated urgent surgery within 24 h of admission. We found that immediately, postoperatively, and during the 6-week follow-up, motor and sensory deficits improved significantly. Sphincteric deficits improved and then plateaued whereas perineal numbness did not improve statistically within 6 weeks. The perioperative morbidity was low with 6%, and the surgical complications included dural tear in one patient and one postoperative seroma of the wound.

Ahn et al. conducted a meta-analysis of 322 patients presenting with cauda equina syndromes from 42 publications; there were significant advantages for patients undergoing surgery within 48 h versus after 48 h.[1] Similarly, Kohles et al. found better outcomes for patients undergoing comparable surgery within 24 versus after 24–48 h.[4] Most studies have supported early decompression[234] but without any sufficient statistical significance.[68] In our study, for 11 patients with bladder or bowel dysfunction and 12 with perineal numbness undergoing surgery within 24 h, the former 11 demonstrated immediate improvement whereas the latter 12 had not significantly improved until 6 postoperative weeks.

SUMMARY

The authors conclude that urgent surgery for patients with acute lumbar disc herniations contributing to severe sensory/motor/sphincteric deficits (e.g., including cauda equina syndromes for the latter), surgery within 24 h results in significant functional improvement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.