Accepted Manuscript Time to Treatment of Cauda Equina Syndrome: A Time to Re-evaluate Our Clinical Decision Mohamad Bydon, M.D. Ziya Gokaslan, M.D. PII:
S1878-8750(14)00219-8
DOI:
10.1016/j.wneu.2014.03.006
Reference:
WNEU 2294
To appear in:
World Neurosurgery
Received Date: 22 November 2013 Accepted Date: 4 March 2014
Please cite this article as: Bydon M, Gokaslan Z, Time to Treatment of Cauda Equina Syndrome: A Time to Re-evaluate Our Clinical Decision, World Neurosurgery (2014), doi: 10.1016/j.wneu.2014.03.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Time to Treatment of Cauda Equina Syndrome: A Time to Re-evaluate Our Clinical Decision Mohamad Bydon, M.D.1; Ziya Gokaslan, M.D.1
RI PT
1. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD Corresponding Author Ziya Gokaslan, MD
SC
The Johns Hopkins Hospital 600 N Wolfe Street Meyer Room 7-109 Baltimore, MD 21287
M AN U
Phone: (443) 287-4934 Fax: (410) 502-3399 [email protected]
AC C
EP
TE D
Disclosures: Ziya Gokaslan is the recipient of research grants from Depuy Spine, AO Spine North America, Medtronic, NREF, Integra Life Sciences, and K2M. He receives fellowship support from AO Spine North America. He holds stock in Spinal Kinetics and US Spine. Mohamad Bydon does not have any disclosures to report.
ACCEPTED MANUSCRIPT
While Cauda Equina Syndrome (CES) is considered to be one of the few operative emergencies in the field of spine surgery, the association between time to treatment and patient outcomes has not been fully established. In 1934, Mixter and Barr fist described CES following an intervertebral disc rupture.5 In 1956, R.N. Shepard identified urgent surgical decompression
RI PT
as a predictor of favorable outcomes.6 Almost 50 years later, Ahn et al calculated time to surgery as a function of patient outcomes in a landmark meta-analysis.1 In that study, the authors found that patients presenting with acute CES had a 48-hour window of opportunity for the
decompression of nerve roots; beyond this time period, neurological function was unlikely to
SC
recover. In 2004, Kohles et al refuted this conclusion due to the lack of study controls (internal validity).4 Upon re-evaluating the results from the Ahn et al meta-analysis published in 2000,
M AN U
Kohles et al asserted that the threshold for time to surgery should in fact be decreased to 24 hours from symptom onset. Likewise, Todd et al conducted an independent meta-analysis, reporting odds ratios with referent controls in order to strengthen the internal validity.7 The authors concluded the odds of bladder function recovery were 3.89 times higher following surgery within 24 hours compared to after 24 hours.
In the current manuscript “Timing of Surgical Intervention in Cauda Equina Syndrome –
TE D
A Systematic Critical Review,” Dr. Anthony Minh Tien Chau and his group at the Australian School of Advanced Medicine in Sydney, Australia critically re-analyzed the findings published by Todd et al in 2005. They cited two important short-comings of the study. One, the metaanalysis was limited in size: 48 patients from three small studies. Two, although the odds ratio of
EP
3.89 suggested a higher likelihood of bladder recovery in the
S1878-8750(14)00219-8
DOI:
10.1016/j.wneu.2014.03.006
Reference:
WNEU 2294
To appear in:
World Neurosurgery
Received Date: 22 November 2013 Accepted Date: 4 March 2014
Please cite this article as: Bydon M, Gokaslan Z, Time to Treatment of Cauda Equina Syndrome: A Time to Re-evaluate Our Clinical Decision, World Neurosurgery (2014), doi: 10.1016/j.wneu.2014.03.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Time to Treatment of Cauda Equina Syndrome: A Time to Re-evaluate Our Clinical Decision Mohamad Bydon, M.D.1; Ziya Gokaslan, M.D.1
RI PT
1. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD Corresponding Author Ziya Gokaslan, MD
SC
The Johns Hopkins Hospital 600 N Wolfe Street Meyer Room 7-109 Baltimore, MD 21287
M AN U
Phone: (443) 287-4934 Fax: (410) 502-3399 [email protected]
AC C
EP
TE D
Disclosures: Ziya Gokaslan is the recipient of research grants from Depuy Spine, AO Spine North America, Medtronic, NREF, Integra Life Sciences, and K2M. He receives fellowship support from AO Spine North America. He holds stock in Spinal Kinetics and US Spine. Mohamad Bydon does not have any disclosures to report.
ACCEPTED MANUSCRIPT
While Cauda Equina Syndrome (CES) is considered to be one of the few operative emergencies in the field of spine surgery, the association between time to treatment and patient outcomes has not been fully established. In 1934, Mixter and Barr fist described CES following an intervertebral disc rupture.5 In 1956, R.N. Shepard identified urgent surgical decompression
RI PT
as a predictor of favorable outcomes.6 Almost 50 years later, Ahn et al calculated time to surgery as a function of patient outcomes in a landmark meta-analysis.1 In that study, the authors found that patients presenting with acute CES had a 48-hour window of opportunity for the
decompression of nerve roots; beyond this time period, neurological function was unlikely to
SC
recover. In 2004, Kohles et al refuted this conclusion due to the lack of study controls (internal validity).4 Upon re-evaluating the results from the Ahn et al meta-analysis published in 2000,
M AN U
Kohles et al asserted that the threshold for time to surgery should in fact be decreased to 24 hours from symptom onset. Likewise, Todd et al conducted an independent meta-analysis, reporting odds ratios with referent controls in order to strengthen the internal validity.7 The authors concluded the odds of bladder function recovery were 3.89 times higher following surgery within 24 hours compared to after 24 hours.
In the current manuscript “Timing of Surgical Intervention in Cauda Equina Syndrome –
TE D
A Systematic Critical Review,” Dr. Anthony Minh Tien Chau and his group at the Australian School of Advanced Medicine in Sydney, Australia critically re-analyzed the findings published by Todd et al in 2005. They cited two important short-comings of the study. One, the metaanalysis was limited in size: 48 patients from three small studies. Two, although the odds ratio of
EP
3.89 suggested a higher likelihood of bladder recovery in the
