BACKGROUND: Factors influencing recovery after decompression surgery for cauda equina syndrome (CES) are not completely identified. The authors aimed to investigate the most valuable predictors (MVPs) of poor postoperative recovery (PPR) in patients with CES and construct a nomogram for discerning those who will experience PPR.
METHODS: Three hundred fifty-six patients with CES secondary to lumbar degenerative diseases treated at Xijing Hospital were randomly divided into training ( N =238) and validation ( N =118) cohorts at a 2:1 ratio. Moreover, 92 patients from the 970 th Hospital composed the testing cohort. Least Absolute Shrinkage and Selection Operator regression (LASSO) was used for selecting MVPs. The nomogram was developed by integrating coefficients of MVPs in the logistic regression, and its discrimination, calibration, and clinical utility were validated in all three cohorts.
RESULTS: After 3 to 5 years of follow-up, the residual rates of bladder dysfunction, bowel dysfunction, sexual dysfunction, and saddle anesthesia were 41.9, 44.1, 63.7, and 29.0%, respectively. MVPs included stress urinary incontinence, overactive bladder, low stream, difficult defecation, fecal incontinence, and saddle anesthesia in order. The discriminatory ability of the nomogram was up to 0.896, 0.919, and 0.848 in the training, validation, and testing cohorts, respectively. Besides, the nomogram showed good calibration and clinical utility in all cohorts. Furthermore, the optimal cutoff value of the nomogram score for distinguishing those who will experience PPR was 148.02, above which postoperative outcomes tend to be poor.
CONCLUSIONS: The first pretreatment nomogram for discerning CES patients who will experience PPR was developed and validated, which will aid clinicians in clinical decision-making.

BACKGROUND: Spinal subarachnoid hematoma (SSH) is a known but rare entity that can cause cauda equina compression. The occurrence of SSH associated with aneurysmal subarachnoid hemorrhage has rarely been described in the literature.
METHODS: A 56-year-old woman presented with subarachnoid hemorrhage secondary to a ruptured middle cerebral artery aneurysm and was managed with coiling embolization without stent assistance. There was no history of either lumbar puncture or the use of anticoagulants. The patient developed severe lumbago radiating to bilateral legs nine days after the procedure. Subsequent magnetic resonance imaging demonstrated a SSH extending from L5 to S2 and wrapping around the cauda equina. The patient was treated with intravenous methylprednisolone (250 mg/day) for four consecutive days, followed by a taper of oral prednisolone (20 mg/day) until complete recovery. Magnetic resonance imaging at one month follow-up revealed complete resolution of the SSH.
CONCLUSIONS: Here, we report a case of acute cauda equina syndrome caused by a SSH after aneurysmal subarachnoid hemorrhage, which will facilitate timely intervention of patients with this disorder.

BACKGROUND: Symptoms of cauda equina syndrome (CES) secondary to degenerative lumbar spine diseases are sometimes mild and tend to be ignored by patients, resulting in delayed treatment. In addition, the long-term efficacy of surgery is unclear.
OBJECTIVE: To determine the predictive factors of CES and post-operative recovery in patients with symptoms lasting > 3 months.
METHODS: From January 2011 to December 2020, data of 45 patients with CES secondary to lumbar disk herniation/lumbar spinal stenosis were collected from a single center. The patients had bladder, bowel or sexual dysfunction and decreased perineal sensation that lasted for > 3 months. A 2-year post-operative follow-up was conducted to evaluate recovery outcomes, which were measured by validated self-assessment questionnaires conducted by telephone and online.
RESULTS: Overall, 45 CES patients (57.8% female; mean age, 56 years) were included. The duration of pre-operative CES symptoms was 79.6 weeks (range, 13-730 weeks). The incidence of saddle anesthesia before decompression was 71.1% (n = 32), bladder dysfunction 84.4% (n = 38), bowel dysfunction 62.2% (n = 28) and sexual dysfunction 64.4% (n = 29). The overall recovery rate of CES after a 2-year follow-up was 64.4%. The rates of the residual symptoms at the last follow-up were as follows: saddle anesthesia 22.2%, bladder dysfunction 33.3%, bowel dysfunction 24.4% and sexual dysfunction 48.9%. Pre-operative saddle anesthesia, overactive bladder and sexual dysfunction were risk factors for poor prognosis after decompression.
CONCLUSIONS: CES patients with symptoms lasting > 3 months may recover after surgery. Sexual dysfunction has a high residual rate and should not be ignored during diagnosis and treatment.

Cauda Equina Syndrome (CES) after Combined Spinal-Epidural Anesthesia (CSEA) is a rare disease that most of the time need surgery to relieve spinal cord compression.
A 34-year-old male patient underwent a procedure for prolapse and hemorrhoids (PPH) under CSEA. Anesthesia and surgery were uneventful. However, the patient gradually experienced urinary retention, lower abdomen and back pain, changes in bowel habits and neurological dysfunction of the lower limbs when the catheter was removed. It was later determined that the patient had Tarlov cyst at the left S1 level in the sacral canal. Finally, the patient completely recovered 20 days after drug conservative therapy onset.
This case suggests that CES might occur even after ordinary CSEA. The risk factors are drug neurotoxicity to ropivacaine and Tarlov cyst, which helped to accumulate ropivacaine. The development of ultrasound-guided CSEA and an ultrasound atlas of the spinal canal are required.

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Background: Spinal fusion is a common surgery, in which vertebrae are fused to restore spinal stability and eliminate pain during movement. The use of an interbody cage facilitates spinal fusion. However, complete cage migration into the dura matter rarely occurs and can be challenging to manage. Case Presentation: A 44-year-old man presented at our spine center with a history of incomplete paraplegia and cauda equina syndrome that had lasted for 2 years and 4 months. This condition developed after he underwent six lumbar spine surgeries to address lower back pain and right-sided sciatica. A structural allograft kidney-shaped cage was found completely within the dura at the level of the L3 vertebra. Durotomy, cage retrieval, and pedicle screw fixation from the L2 to L4 vertebrae were performed. Numbness in both lower limbs markedly decreased within several days of the operation. After four months following the progressive physical therapy, the patient could partially control both urination and defecation. Five months postoperatively, he could stand with slight assistance. Conclusions: Complete intradural cage migration is a rare and serious complication. To the best of our knowledge, this is the first reported case with such a condition in the literature. Even if treatment is delayed, surgical intervention may salvage the remaining neurologic function and may even lead to partial recovery.

Cauda Equina Syndrome (CES) is a relatively uncommon and complex disorder. Recently, there has been a surge in research on CES. Although the research directions are multifarious, the overall research trends are unclear at present. We aimed to identify the 100 most cited articles on CES and analyze the hot spots trends regarding CES related research by bibliometric analysis.
Articles were obtained by conducting an English language search of the Web of Science Core Collection Databases with the keywords \"cauda equina syndrome.\" The initial 390 articles returned from the search were analyzed by VOSviewer. Next, the top 100 most cited articles were further analyzed by title, authors, journal, year of publication, total citations, country of origin, institution, and keywords.
A total of 390 publications were identified. The top 100 most cited articles were listed in descending order of total citations (range: 196-11). These articles originated from 24 countries; among these countries, the United Kingdom contributed the most publications (n = 29). The most prolific journal was Spine (n = 27), and the University of Edinburgh was the most productive institution (n = 9).
The number of publications on CES increased steadily, with a stable rise in recent years. Some publications have been cited more than 100 times, indicating that these findings are widely accepted by relevant clinicians and contribute significantly to the knowledge of CES. This study represents the first bibliometric analysis and visualization of hot spots analysis and research trends on CES. We believe that this will aid clinical researchers in targeting future areas of research.

BACKGROUND: In recent clinical follow-up, it has been vertified that resorption in lumbar disc herniation (LDH) could be of great curative effect in non-surgical treatment for LDH. However, reports of resorption in giant tumor-like LDH are rarely mentioned due to its risk of irreversible neurological damage which could be caused by long-term non-surgical treatment. In our clinical observations, we have found that enhanced MRI helps to distinguish LDH from intradural tumours and to predict the probability of resorption in LDH. We analyzed 8 patients with giant tumor-like LDH who underwent non-surgical treatment, and these patients had resorption during follow-up. All patients were examined with enhanced MRI before treatment, and the type of \"bull\'s eye\" sign classification was determined by images. The MRI protrusion volume(VP), resorption rate(HR%) and JOA score of patients at the first visit and the last follow-up were recorded.
METHODS: 8 patients of Han ethnicity were admitted to the department of orthopedic complaining of low back pain for 1week to 12months. They were diagnosed with giant tumor-like LDH by enhanced MRI.
METHODS: These patients were diagnosed with giant tumor-like LDH.
METHODS: We adopted a non-surgical treatment plan for the patients, including taking oral non-steroidal anti-inflammatory agents and performing rehabilitation exercise. In consideration of the risk of irreversible neurological damage, patients were closely observed during treatment and follow-up. Once the following conditions occur, surgical treatment is required immediately: The symptoms are not signifcantly relieved after 3 to 6 months of non-surgical treatment; The symptoms are aggravated by non-surgica treatment; The clinical manifestations of cauda equina syndrome.
RESULTS: After treated with oral non-steroidal anti-inflammatory agents and rehabilitation exercise, the resorption was accompanied by clinical symptom relief. No neurological damage occurred in all patients, and the clinical symptoms did not recur in the subsequent follow-up.
CONCLUSIONS: Clinicians should fully consider the possibility of resorption prior to surgical treatment in patients with giant LDH. We can predict the probability of resorption in patients with giant LDH based on enhanced MRI. For patients with a high probability of resorption, we can choose non-surgical treatment in the absence of progressive neurological impairment and cauda equina syndrome.

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BACKGROUND: Fungal spondylodiscitis is a rare infectious disease. The secondary lumbar spinal stenosis and postoperative discal pseudocyst were even rarer. The surgical interventions were disputed, yet endoscopic and robot-assisted techniques may be helpful under different circumstances.
METHODS: A 62-year-old female was diagnosed as infectious spondylodiscitis at the L4/5 level and a posterolateral endoscopic debridement was performed after invalid conservative therapy. Causative organism culture revealed a rare fungus, Candida tropicalis. A secondary spinal stenosis with refractory radiculopathy occurred almost 3 years after the first surgery and a successful endoscopic surgery was implemented aiming to decompress the nerve in a minimally invasive way. However, 2 months later, the patient manifested severe acute cauda equina syndrome and radiological examinations suggested a rare postoperative discal pseudocyst. A laminectomy followed by a pseudocystectomy was applied to achieve thorough decompression. An innovative double trajectory system (simultaneous traditional pedicle screw and cortical bone trajectory screw) accompanied by posterolateral fusion was designed and executed by the professional robot-assisted system.
CONCLUSIONS: Endoscopic and robot-assisted techniques may provide alternative solutions for fungal spondylodiscitis and accompanied sequelae.