Early Versus Delayed Decompression in Cauda Equina Syndrome: Neurological and Functional Outcomes

To compare the neurological and functional outcomes of early versus delayed surgical decompression in patients with cauda equina syndrome (CES).

Descriptive study. Place and Duration of the Study: Department of Neurosurgery, Medical Teaching Institution, Mardan Medical Complex, Mardan, Pakistan, from June 2020 to May 2025.

Adult patients diagnosed with CES who underwent surgical decompression were included. Patients were categorised into the early decompression (ED) group (≤48 hours from symptom onset) and the delayed decompression (DD) group (>48 hours from symptom onset). Neurological function was evaluated using the Modified Frankel Scale (MFS) at presentation and at 12-month follow-up. The primary outcome was bladder function recovery, and secondary outcomes included neurological improvement (≥1-grade improvement on the MFS) and the resolution of saddle paraesthesia. The Fisher's exact test was used for statistical analysis.

Thirty-six patients were included (mean age: 34 years; 66.7% male). CES with urinary retention (CES-R) was spotted in 77.8% of the cases. The most frequently involved levels were L5-S1 (55.6%) and L4-L5 (44.4%). Early surgery was performed in 15 patients (41.7%), while 21 (58.3%) underwent delayed surgical decompression. At one-year follow-up, persistent bladder dysfunction was distinctly lower in the ED group (13.3%) compared to the DD group (47.6%; p = 0.040). Saddle paraesthesia was more common in the DD group, without any statistical significance. Overall, 88.9% of patients displayed improvement of ≥1 Frankel grade, and most regained independent ambulation.

Early surgical decompression within 48 hours of symptom onset is linked with significantly better bladder and neurological outcomes in CES. Systemic delays in diagnosis and referral highlight the urgent need for national CES protocols and efficient referral pathways in resource-limited settings.