Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome

A prospective longitudinal inception cohort study of 33 patients undergoing surgery for cauda equina syndrome (CES) due to a herniated lumbar disc. To determine what factors influence spine and urinary outcome measures at 3 months and 1 year in CES specifically with regard to the timing of onset of symptoms and the timing of surgical decompression. CES consists of signs and symptoms caused by compression of lumbar and sacral nerve roots. Controversy exists regarding the relative importance of timing of surgery as a prognostic factor influencing outcome. Post-operative outcome was assessed at 3 months and 1 year using the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) scores for leg and back pain and an incontinence questionnaire. Statistical analysis was used to determine the association between pre-operative variables and these post-operative outcomes with a specific emphasis on the timing of surgery. Surgery was performed on 12 (36%) patients within 48 h of the onset of symptoms including seven patients (21%) who underwent surgery within 24 h. Follow up was achieved in 27 (82%) and 25 (76%) patients at 3 and 12 months, respectively. There was no statistically significant difference in outcome between three groups of patients with respect to length of time from symptom onset to surgery- <24, 24–48 and >48 h. A significantly better outcome was found in patients who were continent of urine at presentation compared with those who were incontinent. The duration of symptoms prior to surgery does not appear to influence the outcome. This finding has significant implications for the medico-legal sequelae of this condition. The data suggests that the severity of bladder dysfunction at the time of surgery is the dominant factor in recovery of bladder function

Cauda equina syndrome: a review of the current clinical and medico-legal position

Cauda equina syndrome (CES) is a rare condition with a disproportionately high medico-legal profile. It occurs most frequently following a large central lumbar disc herniation, prolapse or sequestration. Review of the literature indicates that around 50–70% of patients have urinary retention (CES-R) on presentation with 30–50% having an incomplete syndrome (CES-I). The latter group, especially if the history is less than a few days, usually requires emergency MRI to confirm the diagnosis followed by prompt decompression by a suitably experienced surgeon. Every effort should be made to avoid CES-I with its more favourable prognosis becoming CES-R while under medical supervision either before or after admission to hospital. The degree of urgency of early surgery in CES-R is still not in clear focus but it cannot be doubted that earliest decompression removes the mechanical and perhaps chemical factors which are the causes of progressive neurological damage. A full explanation and consent procedure prior to surgery is essential in order to reduce the likelihood of misunderstanding and litigation in the event of a persistent neurological deficit

The uncertainty of knowing: an analysis of the nature of knowledge in a small business context

It is argued that the tendency for small businesses to operate under conditions of internal and external uncertainty determines and affects the knowledge that is developed and deployed. The article is theoretical in intent and approach and offers a conceptulization of one aspect of the small business in order to stimulate debate and to propose a potential framework for future fieldwork and empirical examination. It is argued that types of knowledge-as-knowing and the 'bundles' that form will vary in 2 ways: 1. There will be differences among small businesses that experience uncertainty, in terms of the knowledge-as-knowing that emerges and is applied. 2. The nature of knowledge and its manifestation may differ depending upon context, suggesting the knowledge and its production and application are essentially contextually contingent and determined