The lived experience of Cauda Equina Syndrome: a qualitative analysis.

STUDY DESIGN: An exploratory qualitative analysis, using semi-structured interviews to investigate the lived experience of Cauda Equina Syndrome (CES). OBJECTIVES: To address the paucity of psychological research into CES and explore patient experiences of living with the injury. SETTING: The study was conducted in the United Kingdom. Recruitment was via two National Health Service spinal services in the South East of England and an online CES charity. METHODS: An interpretative phenomenological analysis (IPA) methodology was employed. Eleven participants took part in the study and completed an interview consisting of seven open ended questions relating to the psychosocial impact of CES. Interviews were audio-recorded, transcribed verbatim and analysed following an IPA procedure. RESULTS: Three superordinate themes were generated. The first, Dissatisfaction with care: 'I felt very abandoned', captured experiences of feeling neglected and disbelieved by the healthcare system and a wish for symptoms to be validated. The second, Hidden to others: 'Nobody knows. It's horrible', spoke to a struggle to gain a social identity in relation to a hidden disability. The third, Changing identities: 'You become someone totally totally different' versus 'You're still the same person', captured a process of renegotiating identity following CES. CONCLUSION: Findings highlight the importance of improving access to support for people with CES, as well as validating and facilitating disclosure of hidden symptoms. There is a clear need for more research into the psychosocial impact of this injury.

The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome.

BACKGROUND: Cauda equina syndrome (CES) is a rare neurologic complication of lumbar herniated disc for which emergency surgical decompression should be undertaken. Despite the common belief that the restoration of functions that are affected by CES can take several years postoperatively, follow up seldom exceeds the first year after surgery. Long term outcome of especially micturition, defecation and sexual function-which are by definition affected in CES-are unknown. The aim of this study is to evaluate 1) postoperative long term outcome of micturition, defecation and sexual function in CES patients 2) attitude of patients towards received hospital care with regard to (recovery of) these functions. METHODS: CES patients were selected by screening the records of all patients operated on lumbar herniated disc in our university hospital between 1995-2010. A questionnaire was sent to the selected CES patients evaluating current complaints of micturition, defecation and sexual function and attitude towards delivered care with focus on micturition, defecation and sexual function. RESULTS: Thirty-seven of 66 eligible CES patients were included (response rate 71%, inclusion rate 56%). Median time after surgery was 13.8 years (range 5.8-21.8 years). Dysfunction at follow up was highly prevalent: 38% micturition dysfunction, 43% defecation dysfunction and 54% sexual dysfunction. Younger age at presentation was associated with sexual dysfunction at follow up: for every year younger at presentation, odds ratio for sexual dysfunction at follow up was 1.11 (p = 0.035). Other associations with outcome were not identified. Two-third of the CES patients wished their neurosurgeon had given them more prognostic information about micturition, defecation and sexual function. CONCLUSION: The presented data demonstrate that dysfunction of micturition, defecation and sexual function are still highly prevalent in a large number of CES patients even years postoperatively. These alarming follow up data probably have a devastating effect on personal perceived quality of life, which should be studied in more detail. CES patients communicate a clear demand for more prognostic information. The presented figures enable clinicians to inform their CES patients more realistically about long term postoperative outcome of micturition, defecation and sexual function after surgical intervention.

Metabolomic Changes in Rat Model of Cauda Equina Injury.

BACKGROUND: To show the differences of metabolomic changes in a rat model of cauda equina injury (CEI) and find potent metabolic biomarkers of CEI. METHODS: A total of 28 Sprague-Dawley rats were used in this study. After the rats were given anesthesia and fixed in a prone position, a piece of silicone block was placed into the epidural space below the lamina. Behavior tests including the Basso, Beattie, and Bresnahan open field locomotor scale and an inclined plane test were conducted 1 day and 2 days after surgery. The cauda equina tissue was collected 12 hours, 1 day, and 2 days after surgery. Ultraperformance liquid chromatography coupled with quadruple time-of-flight mass spectrometry was used for a quantitative analysis of cauda equine metabolic changes in rats from different groups. The differences between the metabolic profiles of the rats in 4 groups were analyzed using partial least squares discriminant analysis. RESULTS: In behavior tests and histologic analyses given 2 days after surgery, the animals showed remarkable organ dysfunction and pathologic damage. Metabolic profiles showed remarkable differences between the control and model groups. Thirty-four potential CEI metabolite biomarkers were identified between the control group and different time-point model groups. These potential biomarkers appeared in 15 metabolic pathways. CONCLUSIONS: Our results may improve the cause of CEI and provide a basis for clinical diagnosis and locating biomarkers in the early stages of the pathologic process of CEI.

Coexistence of pain and depression predicts poor 2-year surgery outcome among lumbar spinal stenosis patients.

BACKGROUND: Lumbar spinal stenosis is a common cause of back and leg pain with the most severe cases treated surgically. Regarding the surgery outcome, the importance of early postoperative depression and pain is unknown. AIMS: To examine whether the coexistence of pain and depressive symptoms on 3-month follow-up predicts the 2-year surgery outcome. METHODS: 93 patients (mean age 62 years) with symptomatic lumbar spinal stenosis underwent decompressive surgery. They completed the same set of questionnaires, 3 months, 1 year and 2 years postoperatively. Depression was assessed with the 21-item Beck Depression Inventory (BDI). Physical functioning and pain were assessed with the Oswestry Disability Index, the Stucki Questionnaire, self-reported walking ability, the visual analogue scale (VAS) and pain drawing. Comparisons were made between groups according to the "misery" (i.e. the coexistence of elevated pain and depression on 3-month follow-up) status. Logistic regression analysis was used to examine the factors independently associated with a poor surgery outcome on 2-year follow-up. RESULTS: The patients in the misery group (n=24) showed greater symptom severity and greater disability than the patients in the non-misery group (n=69) at all follow-up stages. No clinical improvement was seen in the misery group during the follow-up. An independent association was observed between belonging to the misery group and 2-year disability, symptom severity and poor walking capacity. CONCLUSIONS: Even moderately increased VAS and BDI scores, when presenting simultaneously on an individual patient level during the early postoperative period, imply a strong clinical burden and a risk factor for poor recovery. The assessment of pain and depressive symptoms is encouraged.

Cauda equina syndrome with normal MR imaging.

The aim of this study was to compare the clinical characteristics of patients with and without abnormal MR imaging admitted to a neurosurgical unit with suspected cauda equina syndrome using a retrospective study of consecutive admissions to a regional neurosurgical unit over a 10-month period. Clinical details were obtained from the case notes. A lumbar spine MR scan to investigate possible cauda equina syndrome was performed in 66 patients. There were no significant differences between those with abnormal imaging (n = 34, 52%) and those with a normal scan (n = 32, 48%) in respect of sex, clinical history or features recorded on examination. Those with normal imaging had a high frequency of weakness (n = 18, 59%), saddle numbness (n = 17, 57%), leg numbness (n = 24, 80%), urinary incontinence (n = 13, 54%) and urinary retention (n = 9, 53%). A large number of patients present to neurosurgical units with symptoms suggestive of cauda equina syndrome without any radiological evidence of structural pathology. While some may have had an alternative organic cause, we propose that these symptoms may have a "functional" origin in many patients.