Reassessing bladder recovery in cauda equina syndrome: long-term outcomes after surgical decompression:a systematic
Elie Najjar1, Rodrigo Muscogliati2, Charlie Trumble3
1Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.
Background Context:
Bladder dysfunction is the most clinically significant manifestation of cauda equina syndrome (CES) and a key determinant of long-term disability. However, reported recovery rates after surgical decompression vary widely, and the true prevalence of persistent bladder dysfunction remains unclear.
Purpose:
To evaluate long-term bladder outcomes following surgical decompression for degenerative spine related cauda equina syndrome and to quantify the prevalence of persistent bladder dysfunction.
Study Design/Setting:
Systematic review and meta-analysis of observational studies.
Patient Sample:
Patients with cauda equina syndrome secondary to degenerative lumbar spine disease undergoing surgical decompression.
Outcome Measures:
Persistent bladder dysfunction at ≥12 months follow-up, including urinary retention, incontinence, voiding dysfunction, need for catheterization, abnormal urodynamics, or validated urinary symptom scores.
Methods:
A systematic review was conducted according to PRISMA guidelines. MEDLINE, Embase, and PubMed were searched from inception to 16 December 2025 for studies reporting long-term bladder outcomes following surgical decompression for CES secondary to degenerative spine disease. Observational studies with ≥12 months follow-up were included. Data on study characteristics, CES subtype, timing of surgery, and bladder outcomes were extracted. Random-effects meta-analysis was used to estimate the pooled prevalence of persistent bladder dysfunction. Risk of bias was assessed using Joanna Briggs Institute critical appraisal tools.
Results:
Sixteen studies comprising 987 patients were included. Persistent bladder dysfunction at final follow-up was reported in 285 patients, corresponding to a pooled prevalence of 32.6% (95% CI: 23.4%-41.9%; I²=89.8%). Among patients presenting with preoperative bladder dysfunction, crude paired data demonstrated persistent dysfunction in 130/278 patients (46.8%). In subgroup meta-analysis of studies reporting outcomes specifically in this population (8 studies; n=422), the pooled prevalence of persistent dysfunction was 29.7% (95% CI: 20.4-39.1). Studies consistently reported worse outcomes in patients presenting with urinary retention compared with incomplete CES. Evidence regarding the effect of surgical timing on long-term bladder outcomes was heterogeneous and inconclusive.
Conclusions:
Approximately one-third of patients undergoing decompression for CES secondary to degenerative lumbar pathology have persistent bladder dysfunction at long-term follow-up. Preoperative clinical severity, particularly the presence of urinary retention, appears to be an important clinical factor associated with recovery, although evidence from adjusted analyses remains limited. Standardized outcome definitions and prospective studies are needed to improve prognostic stratification and patient counselling.