Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

confirmed CES

1st line – decompression surgery

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ACUTE
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confirmed CES
1st line – 

decompression surgery

Decompression surgery should be performed as soon as possible. Although surgery within 48 hours of symptom onset has been used by some clinicians as a guide, this has been challenged, and remains controversial. It is likely that the level of neurological dysfunction at the time of surgery (rather than time since symptom onset) is the most significant determinant of prognosis.[38][39][40] One retrospective cohort study of 20,924 patients with CES reported that patients undergoing surgical decompression on hospital day 0 or 1 had better improved inpatient outcomes, including lower complication and mortality rates, than patients having surgery on day 2 or later.[41] Evidence on the benefits of earlier surgery (e.g., within 24 hours) is equivocal.[4][38][42][40] This may be due to differences in neurological dysfunction among participants; some studies suggest that surgery within 24 hours of symptom onset may reduce postoperative bladder dysfunction in patients with incomplete CES, but not in patients with CES with urinary retention, compared with surgery between 24 and 48 hours.[43][44]

Therefore, as the 48-hour time window is controversial, urgent surgery should not be delayed, especially since the precise time of symptom onset can be difficult to define.[39][40] British Association of Spine Surgeons guidelines recommend that surgery should take place as soon as possible, while taking into account the duration and clinical course of symptoms and signs, as well as the potential for increased morbidity when operating at night.[1][23][24]

The goal of surgery is to alleviate compression of the cauda equina, which may be achieved through a number of surgical techniques (e.g., wide-decompressive laminectomy, lumbar microdiskectomy). The appropriate surgical technique should be chosen based on pathology and the experience of the surgeon.[4]

Intra-operative monitoring of somatosensory and motor-evoked potentials allows for evaluation of radiculopathy and neuropathy, but is not a necessary part of urgent procedures.[45]

Plus – prevention of venous thromboembolism

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ACUTE
|
confirmed CES
Plus – 

prevention of venous thromboembolism

Treatment recommended for ALL patients in selected patient group

All patients should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.[48]

Pharmacological prophylaxis should be used unless contraindicated; non-pharmacological measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding, especially in the preoperative phase.[48]

See Venous thromboembolism (VTE) prophylaxis.

Plus – maintenance of volume and blood pressure

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ACUTE
|
confirmed CES
Plus – 

maintenance of volume and blood pressure

Treatment recommended for ALL patients in selected patient group

Treatment of autonomic dysfunction and prevention of resultant changes in blood pressure may be required, as this may contribute to further neurological impairment.

In the acute setting, treatment consists of central line placement, volume resuscitation, and vasopressors.

Plus – prevention of gastric stress ulcers

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ACUTE
|
confirmed CES
Plus – 

prevention of gastric stress ulcers

Treatment recommended for ALL patients in selected patient group

Prevention of stress ulceration with a proton-pump inhibitor (e.g., omeprazole) or an H2 antagonist (e.g., famotidine) is indicated for at least 4 weeks following surgery.[49]

Primary options

omeprazole: 20-40 mg orally once daily

OR

famotidine: 40 mg orally once daily; 20 mg intravenously every 12 hours

Plus – bladder and bowel management

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ACUTE
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confirmed CES
Plus – 

bladder and bowel management

Treatment recommended for ALL patients in selected patient group

Bladder and bowel function should be assessed and monitored. If bladder catheterisation is needed, an intermittent catheter is preferred, as it is associated with lower rates of urinary tract infection and urethral trauma. An indwelling catheter may be used if intermittent catheterisation is not feasible.[50][51] Anticholinergic medications are often part of management. Invasive procedures may be considered for ongoing problems.[50]

A bowel programme (to help to prevent involuntary bowel movements, constipation, and impaction of the bowels), laxatives, and/or bowel evacuation may be required.

Plus – other supportive therapies

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ACUTE
|
confirmed CES
Plus – 

other supportive therapies

Treatment recommended for ALL patients in selected patient group

Risk assessment for pressure ulcers should be carried out. Preventive approaches include regular manual (or automatic) turning for patients on bed rest, encouraging patients who are not on bed rest to mobilise regularly (every few hours), and use of pressure relieving devices. See Pressure ulcers.

Nutritional support should include isotonic feeds and evaluation of dysphagia.

Mechanically assisted ventilation or manually assisted cough may be required.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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