The Spine Journal 21 (2021) 803−809

Clinical Study
Long-term rates of bladder dysfunction after decompression
in patients with cauda equina syndrome
Henry Seidel, BSa, Sarah Bhattacharjee, BSa, Sean Pirkle, BAa,
Lewis Shi, MDb, Jason Strelzow, MDb, Michael Lee, MDb,
Mostafa El Dafrawy, MDb,*
a
Pritzker School of Medicine at The University of Chicago, 924 E. 57th St, Suite 104, Chicago, IL 60637, USA
b
The University of Chicago, Department of Orthopaedic Surgery and Rehabilitation Medicine, The University of Chicago
Hospitals, Duchossois Center for Advanced Medicine, MC 3079, 5758 S. Maryland Avenue, Dept 4B, Chicago, IL 60637, USA
Received 31 October 2020; revised 6 December 2020; accepted 4 January 2021

Abstract BACKGROUND CONTEXT: Cauda equina syndrome (CES) occurs due to compression of the
lumbar and sacral nerve roots and is considered a surgical emergency. Although the condition is
relatively rare, the associated morbidity can be devastating to patients. While substantial research
has been conducted on the timing of treatment, the literature regarding long-term rates of bladder
dysfunction in CES patients is scarce.
PURPOSE: The aim of this study was to identify long-term rates of bladder dysfunction in CES
patients and to compare those rates to non-CES patients who underwent similar spinal
decompression.
STUDY DESIGN/SETTING: Retrospective database study.
PATIENT SAMPLE: The CES cohort was comprised of 2,362 patients who underwent decom-
pression surgery following CES diagnosis with a 5-year follow-up. These patients were matched to
9,448 non-CES control patients who underwent spinal decompression without a diagnosis of CES.
OUTCOME MEASURES: Diagnosis of bladder dysfunction, surgical procedure to address blad-
der dysfunction
METHODS: Using the national insurance claims database, PearlDiver, CES patients who under-
went decompression surgery were identified and 1:4 matched to non-CES patients who underwent
similar spinal decompression surgery. The 1-year, 3-year, and 5-year rates of progression to a blad-
der dysfunction diagnosis and surgical intervention to manage bladder dysfunction were recorded.
The CES and non-CES groups were compared with univariate testing, and an analysis of risk fac-
tors for bladder dysfunction was performed with multivariate logistic regression analysis.
RESULTS: A total of 2,362 CES patients who underwent decompression surgery were identified
and matched to 9,448 non-CES control patients. After 5 years, CES patients had a 10%−12%
increased absolute risk of continued bladder dysfunction and a 0.7%−0.9% increased absolute risk
of undergoing a surgical procedure for bladder dysfunction, as compared to matched non-CES
patients. Multivariate analysis controlling for age, sex, obesity, tobacco use, and diabetes, identified
CES as independently associated with increased 5-year risk for bladder dysfunction diagnosis (odds
ratio [OR]: 1.72; 95% confidence interaval [CI] 1.56−1.89; p<.001) and procedure (OR: 1.40; 95%
CI 1.07−1.81; p=.012).
CONCLUSIONS: Understanding the long-term risk for bladder dysfunction in CES patients is
important for the future care and counseling of patients. Compared to non-CES patients who under-
went similar spinal decompression, CES patients were observed to have a significantly higher long-

FDA device/drug status: Not applicable.
Author disclosures: HS: Nothing to disclose. SB: Nothing to disclose.
SP: Nothing to disclose. LS: Consulting: Depuy (B); Speaking and/or
Teaching Arrangements: Arthrex (B). JS: Consulting: Synthes (B),
Acumed (B), Bone Support (B); Speaking and/or Teaching Arrangements:
Acumed (A). ML: Consulting: Depuy synthes (C); Stryker spine (C);
Globus (B). MED: Nothing to disclose.
Sources of Funding: No external sources of funding were involved in
this study.
*Corresponding author. The University of Chicago, Department of
Orthopaedic Surgery and Rehabilitation Medicine, 5758 S. Maryland Ave-
nue, Dept. 4B, Chicago, IL 60637. Tel.: 773-834-3531.
E-mail address: meldafrawy@bsd.uchicago.edu (M. El Dafrawy).

https://doi.org/10.1016/j.spinee.2021.01.002
1529-9430/© 2021 Elsevier Inc. All rights reserved.
804 H. Seidel et al. / The Spine Journal 21 (2021) 803−809
term likelihood for both bladder dysfunction diagnosis and urologic surgical procedure.
Elsevier Inc. All rights reserved.
Keywords: Cauda equina syndrome; Bladder dysfunction; Spinal decompression; Complications; Long-term rates;
Matched analysis
Introduction
Cauda equina syndrome (CES) occurs due to compression
of the lumbar and sacral nerve roots and is most frequently
caused by disc herniation [1,2], followed by rarer etiologies
including spinal stenosis, epidural hematoma, spinal neoplasm,
abscess, and trauma [3−6]. The symptoms defining CES
remain broad, as patients may present with a constellation of
lower back pain, perianal hypoesthesia, focal neurologic deficits
in the lower limb, and bowel, bladder or sexual impairment
[7,8]. Various patterns have been described in the literature and
are often referred to as complete (CES-R) or incomplete (CES-
I) based on the extent of urinary retention [9].
The widely accepted treatment for CES is decompres-
sion with laminectomy, although the specific technique is
indicated by the nature of the compressive pathology
[10]. Regardless of approach, the most important, and
best studied, element of management is time to surgery,
as strong evidence has shown better outcomes among
patients treated within 48 hours of symptom onset [11
−13]. For this reason, CES is considered one of a few
spine surgical emergencies. Yet, even with timely treat-
ment, recovery is often complicated by longstanding
bowel, bladder, and sexual dysfunction [14−16]. Bladder
dysfunction among patients with CES includes urinary
incontinence, retention, frequency, and other abnormali-
ties of urination [10,11,17]. Ultimately, detailed informa-
tion regarding long-term outcomes remains limited, as
few peer-reviewed studies have attempted to define these
rates, and existing analyses are hindered in part by the
low relative incidence of CES (1 in 33,000−100,000 peo-
ple annually), incongruencies in definitions, and lack of
follow-up [14,15,18]. As Korse et al. discuss in their arti-
cle, there remains a clear need for more robust prognostic
data with respect to bladder dysfunction after CES [15].
This issue is particularly important in the context that
setting appropriate postoperative expectations has been
intimately tied to patient satisfaction scores, and break-
downs of physician-patient communication represents a
dominant theme in studies assessing the subsequent inci-
dence of medical malpractice lawsuits [18−21].
With thousands of cases in a national database, here we
attempt to more clearly define the rates of bladder dysfunc-
tion in CES patients following decompression surgery.
Through a matched analysis, we investigate the likelihood
for bladder dysfunction in CES patients compared to those
undergoing similar decompression procedures for non-CES
indications. We examine the 5-year rates at which patients
were diagnosed with bladder dysfunction and required
operative intervention for this diagnosis.
© 2021
Material and methods
Database
This retrospective database study used the nationwide
Medicare Standard Analytic File (SAF) insurance claims
dataset, available through the PearlDiver database (Pearl-
Diver Inc, Fort Wayne, IN). The SAF dataset consists of
51 million records of Medicare orthopaedic patients from
2005 to 2014. Billing codes are identifiable in the database
as Current Procedural Terminology (CPT) codes and Inter-
national Classification of Diseases, 9th Revision (ICD-9)
diagnostic and procedural codes. All records are anony-
mized and HIPAA compliant; and this study was deter-
mined exempt from Institutional Review Board (IRB)
under IRB18-0215.
Patient selection
The database was queried with ICD-9 and CPT codes for
all CES patients who underwent spinal decompression sur-
gery following a CES diagnosis (Appendix A). To guaran-
tee all patients were enrolled in the study throughout the
duration of the intended 5-year follow-up period, patients
who left the database at any time or did not have continu-
ously active records for any reason were excluded from fur-
ther study. Using the PearlDiver supercomputer, patients
with CES were matched to patients who similarly under-
went spinal decompression surgery in the absence of a diag-
nosis of CES in the medical record. The matched analysis
was performed in a 1:4 ratio, matching by the parameters of
age, sex, obesity, tobacco use, and diabetes, as these demo-
graphics and comorbidities have been shown to be impor-
tant risk factors for bladder dysfunction [22−24]. A 1:4
ratio was chosen for the match in order to adequately power
this study [25,26]. Patients who underwent other spine pro-
cedures in addition to decompression, such as lumbar
arthrodesis or osteotomy, were excluded from this study to
ensure that the CES patients were matched to non-CES
patients who experienced similar surgical treatment.
The age and sex demographic factors, as well as the
comorbidities of obesity, diabetes, and tobacco use were
assessed within the two groups. Diagnoses and procedures
for bladder dysfunction were identified with CPT and ICD-
9 codes and can be viewed in their entirety in the Appendix.
Since CES patients have been shown to experience a wide
range of bladder dysfunction [10,11,17], diagnosis of blad-
der dysfunction was defined broadly by incontinence, reten-
tion, urination frequency, functional disorders of the
bladder, and other abnormalities of urination (Appendix B).
 H. Seidel et al. / The Spine Journal 21 (2021) 803−809
The outcome of future urologic procedure consisted of pro-
cedures for incontinence and overactive bladder, which
included but were not limited to urethropexy, suspension
and sling procedures, and nerve stimulation (Appendix C).
The 1-year, 3-year, and 5-year rates of bladder dysfunction
diagnosis, as well as progression to a procedure for bladder
dysfunction were recorded for the CES cohort and the non-
CES control group. Finally, the groups were stratified by
sex and a subanalysis was conducted to assess the rates of
bladder dysfunction procedures and diagnoses in male and
female patients.
Statistical analysis
Univariate logistic regression was employed to compare
the rates of bladder dysfunction diagnosis and procedure
between the two cohorts at 1, 3, and 5 years following index
decompression surgery. Significance was determined at an
alpha level of 0.05.
To assess the independent association of progression to
bladder dysfunction, multivariate logistic regression analy-
sis was performed on patients of both decompression
cohorts, taking into account the variables of CES diagnosis,
age, obesity, tobacco use, and diabetes. Adjusted odds
ratios were calculated. All statistical analysis was con-
ducted through the R statistical package of the PearlDiver
computer.
Results
Patient matching
A total of 2,362 CES patients who underwent decom-
pression surgery were identified in the database and were
matched to 9,448 non-CES control patients. After match-
ing, the two groups were comprised of patients from similar
age groups, with a mean age within the range of 70
−74 years for both groups. The two groups also had similar
sex demographics, as well as similar proportions of patients
reporting comorbidities of obesity, diabetes, and tobacco
use (Table 1).
Outcome measures
Around 17.3% of CES patients received a diagnosis of
bladder dysfunction after 1 year, 28.3% after 3 years, and
37.6% after 5 years from the index procedure. These values
compare to 7.5%, 17.6%, and 26.1%, respectively, in the
non-CES control group. In the univariate analysis, the CES
cohort showed significantly higher rates of bladder dysfunc-
tion diagnosis compared to the non-CES control group at all
timepoints (p<.001; Fig. 1).
Around 1.3% of CES patients required a bladder dys-
function procedure after 1 year, 2.4% after 3 years, and
3.3% after 5 years. Consistent with the trend in bladder dys-
function diagnosis, in univariate analysis the non-CES con-
trol group showed significantly decreased progression to a
805
bladder dysfunction procedure: 0.6% after 1 year (p<.001),
1.6% after 3 years (p=.01), and 2.4% after 5 years (p=.01;
Fig. 2).
In the sub-analysis after stratification by sex, the five-
year rate of progression to bladder dysfunction diagnosis in
CES patients was 35.5% in females and 39.7% in males
(p=.035). The 5-year rate of progression to a bladder dys-
function procedure was 4.7% in females and 1.9% in males
(p<.001).
Multivariate analysis
In the multivariate logistic regression analysis, CES
diagnosis (odds ratio [OR]: 1.72; 95% confidence interval
[CI] 1.56−1.89; p<.001), age groups of 75−79 years (OR:
1.17; 95% CI 1.01−1.36; p=.03), 80−84 years (OR: 1.43;
95% CI 1.23−1.67; p<.001) and over 85 years (OR: 1.54;
95% CI 1.27−1.87; p<.001), obesity (OR: 1.34; 95% CI
1.23−1.47; p<.001), tobacco use (OR: 1.11; 95% CI 1.02
−1.20; p=.016), and diabetes (OR: 1.32; 95% CI 1.22
−1.44; p<.001) were identified as independently associated
with higher 5-year likelihood for receiving a diagnosis of
bladder dysfunction (Table 2). The age group of 65
−69 years (OR: 0.81; 95% CI 0.70−0.94; p=.006) was
associated with a lower rate of diagnosis. In multivariate
analysis of bladder dysfunction procedures, CES (OR: 1.40;
95% CI 1.07−1.81; p=.012) and obesity (OR: 1.29; 95% CI
1.00−1.65; p=.045) were found to be independently associ-
ated with higher 5-year likelihood for an operative interven-
tion (Table 3). The age groups of 65−69 years (OR: 0.57;
95% CI 0.38−0.85; p=.005) and over 85 years (OR: 0.52;
95% CI 0.27−0.93; p=.034) were associated with a lower
rate of bladder dysfunction procedure.
Discussion
Bladder dysfunction is a troublesome complication for
patients, impacting quality of life and psychosocial well-
being. Patients with bladder dysfunction experience higher
rates of depression, increased sleep disturbance, more
expensive paraprofessional services and home care costs,
and report worse self-perceived overall health [27−30].
Thus, a comprehensive understanding of the long-term
prognosis of bladder function in CES patients is important
for improving patient counseling and setting realistic post-
operative expectations. Here, we identified the long-term
rates of bladder dysfunction diagnosis and surgical inter-
vention for bladder dysfunction among CES patients treated
with decompression surgery. Additionally, through a
matched analysis, we sought to determine if CES patients
had an increased long-term likelihood for bladder dysfunc-
tion compared to patients undergoing similar decompres-
sion procedures for non-CES indications.
In this study, after matching to non-CES controls who
underwent similar decompression surgeries, the rate of
bladder dysfunction and progression to surgical interven-
tion was observed to be significantly higher among patients
806 H. Seidel et al. / The Spine Journal 21 (2021) 803−809

Table 1
Demographics and comorbidities of patients from the CES cohort and the non-CES matched control group

Characteristic CES* Cohort (N=2,362) Non-CES Control (N=9,448) p

N % N %
Age
<65 288 12.2 1152 12.2 1.00
65−69 506 21.4 2024 21.4 1.00
70−74 512 21.7 2048 21.7 1.00
75−79 514 21.8 2056 21.8 1.00
80−84 388 16.4 1552 16.4 1.00
>85 154 6.5 616 6.5 1.00
Sex
Female 1193 50.5 4772 50.5 1.00
Male 1169 49.5 4676 49.5 1.00
Comorbidity
Diabetes 1320 55.9 5280 55.9 1.00
Obesity 715 30.3 2860 30.3 1.00
Tobacco 1058 44.8 4232 44.8 1.00
* Cauda equina syndrome.

Fig. 1. Long-term rates of bladder dysfunction diagnosis in CES patients compared to matched non-CES patients who underwent similar spinal decompres-
sion surgery. Error bars represent 95% confidence internals.

with CES. Additional independent associations include old
age, obesity, and diabetes comorbidity. After stratifying by
sex, we report that both male and female CES patients
experience bladder dysfunction at high rates, with females
statistically more likely to have a surgical intervention to
manage symptoms of bladder dysfunction. This finding was
expected, as the likelihood for concomitant bladder dys-
function among women may be higher compared to men.
Our observed rate of bladder dysfunction among CES
patients (37.6%) is consistent with prior studies. Shapiro et
al. found 4 of 14 CES patients (29%) experienced inconti-
nence [31]. In a study of 42 patients, McCarthy et al.
describe a similar rate, with 14 patients (33%) reporting uri-
nary incontinence at follow-up [14]. Qureshi and Sell con-
ducted a prospective study on CES patients and used a
patient questionnaire to assess bladder dysfunction [32],
and at an early follow-up of three months, 12 of 25 (48%)
patients had reported inadvertent leakage of urine. After a
year, three patients regained bladder function and two new
patients lost function, resulting in 11 of 25 (44%) of
patients experiencing bladder dysfunction. Our results fall
within the range of these previous findings, albeit lower
than study by Qureshi and Sell. The higher rate in Qureshi
and Sell’s study may be partially explained by their use of
patient questionnaires to identify bladder dysfunction,
rather than relying on diagnosis. Furthermore, to our knowl-
edge, there have been no prior investigations into the long-
term rate of surgical intervention to address bladder dys-
function in CES patients. While the literature regarding
incidence of bladder dysfunction procedures among the
 H. Seidel et al. / The Spine Journal 21 (2021) 803−809 807

Fig. 2. Long-term progression to surgical intervention for bladder dysfunction in CES patients compared to matched non-CES patients who underwent simi-
lar spinal decompression surgery. Error bars represent 95% confidence internals.

general population is scarce, one study reported 1.6 out of

Table 2 1,000 woman undergo procedures for urinary incontinence
Multivariate logistic regression analysis of bladder dysfunction diagnosis
5 years after decompression surgery controlling for CES, age, obesity,
[33]. In this study, we report that after 5 years, 3.3% of all
tobacco use, and diabetes CES patients, and 4.7% of all female CES patients, under-
went a surgical procedure to manage bladder dysfunction.
Variables Odds ratio p
These data suggest CES patients are considerably more
CES* 1.72 (1.56−1.89) <.001 likely to undergo surgery for the treatment of bladder dys-
Age 65−69 0.81 (0.70−0.94) .006 function compared to the general population.
Age 70−74 0.94 (0.81−1.09) .41
While previous small cohort studies have investigated
Age 75−79 1.17 (1.01−1.36) .03
Age 80−84 1.43 (1.23−1.67) <.001 bladder dysfunction in CES patients, here we attempt to iso-
Age >85 1.54 (1.27−1.87) <.001 late the effects of CES on bladder dysfunction in a large
Obesity 1.34 (1.23−1.47) <.001 number of matched CES patients to non-CES patients who
Tobacco use 1.11 (1.02−1.20) .016 underwent similar open intervention. In our univariate anal-
Diabetes 1.32 (1.22−1.44) <.001
ysis, CES patients were observed to carry a significantly
The bold text indicates statistically significant variables with p<0.05. higher rate of bladder dysfunction diagnosis and procedures
* Cauda equina syndrome.
at each time-point assessed compared to the non-CES con-
trols, as expected. A simplistic interpretation of these data
is that CES patients have a 10%−12% increased absolute
Table 3 risk of carrying continued bladder dysfunction diagnoses as
Multivariate logistic regression analysis of bladder dysfunction procedure compared to non-CES patients. In addition, CES patients
5 years after decompression surgery controlling for CES, age, obesity, have a 0.7%−0.9% increased absolute risk of undergoing a
tobacco use, and diabetes
procedure for their bladder dysfunction than non-CES
Variables OR (95% CI) p patients. There is a scarcity of normative reference data
CES* 1.40 (1.07−1.81) .012 regarding bladder dysfunction in CES patients. Though this
Age 65−69 0.57 (0.38−0.85) .005 analysis is blunt, this information can be useful in counsel-
Age 70−74 0.79 (0.55−1.14) .21 ing CES patients.
Age 75−79 0.72 (0.49−1.06) .093 The findings from the multivariate analysis identify
Age 80−84 0.69 (0.45−1.04) .078
CES as independently associated with 5-year risk for
Age >85 0.52 (0.27−0.93) .034
Obesity 1.29 (1.00−1.65) .045 bladder dysfunction diagnosis. Diabetes, tobacco use,
Tobacco Use 0.73 (0.58−0.92) .010 obesity, and old age were also identified as risk factors,
Diabetes 1.19 (0.94−1.52) .16 which aligns with previous studies on bladder dysfunc-
The bold text indicates statistically significant variables with p<0.05. tion [22−24]. In our analysis regarding procedures for
* Cauda equina syndrome. bladder dysfunction, only CES and obesity were
808 H. Seidel et al. / The Spine Journal 21 (2021) 803−809
independently associated with a higher rate for operative
intervention. In alignment with the diagnosis results,
younger age was protective against a bladder dysfunction
procedure. Contrary to expectations, age above 85 years
was also found to be protective against a procedure. This
may be explained by physicians and elderly patients
electing to manage bladder dysfunction nonoperatively.
Additionally, tobacco use was observed to be protective.
As smoking has been linked to worse postoperative out-
comes, tobacco users may be seen as less suitable candi-
dates for elective bladder dysfunction surgeries [34].
Ultimately, even after accounting for demographic and
comorbidity risk factors through multivariate analysis,
CES was found to be independently associated with a
higher 5-year likelihood of bladder dysfunction diagnosis
and the need for surgical management.
The authors recognize several limitations of the present
study. First, due to the utilization of a national insurance
database, our results are limited to billing codes. Patients
who experience bladder dysfunction may not seek treatment
or report their symptoms to a medical provider, thus it is
possible our reported value may be an underestimation of
the true incidence [35]. Additionally, the ICD diagnostic
codes for bladder dysfunction overlap with many other
pathologies. Thus, this investigation was not intended to
demonstrate causality between CES and future bladder dys-
function, but rather the purpose was to observe overall
trends of bladder dysfunction in these patients. The
matched analysis provided a clearer picture of the increased
incidence of bladder dysfunction in CES patients, as there
was an appreciable difference between the CES patients to
non-CES decompression control patients. Since many of
the acute bladder dysfunction symptoms that CES presents
with are categorized under the same ICD diagnostic codes
as the long-term bladder dysfunction complications, we
could not control for persisting acute dysfunction that may
have contributed to the bladder dysfunction diagnoses in
this study. It is also important to note that CES is a reflec-
tion of a constellation of symptoms and as such, here we
were unable to stratify by different patterns of CES symp-
toms, detect the severity of bladder dysfunction that may
have occurred prior to decompression surgery as a result
of acute CES, or control for the various underlying
pathologies that can cause CES which may have an unde-
termined effect on long-term complication rates. Further-
more, our study is limited by the claims-based practices
of Medicare, which, prior to 2010, were reported quar-
terly rather than by calendar date. This restricted our
ability to investigate the timing between CES diagnosis
and spinal decompression with absolute granularity.
However, based off a sub-analysis of patients in this
study who underwent decompression after 2010, 93% of
patients had decompression within 48 hours of CES diag-
nosis. Therefore, the authors feel confident the vast
majority of patients in our study underwent treatment
within the recommended 48-hour period.
Conclusions
In a large database study design, we quantified the high
rate of bladder dysfunction in CES patients treated surgi-
cally. Patients with CES, when compared to non CES
patients, have roughly a 10%−12% increased absolute risk
of carrying a continued bladder dysfunction diagnosis. Sim-
ilarly, patients with CES have a 0.7%−0.9% increased
absolute risk of undergoing a procedure for the bladder dys-
function as compared to non CES patients. The data from
our multivariate analysis suggest that CES itself is associ-
ated with poorer bladder outcomes as defined by both
symptom severity requiring physician visit/diagnosis as
well as operative management. As setting expectations for
recovery is integral to patient satisfaction, these data may
be useful when counseling patients with CES regarding
their bladder dysfunction. By improving our understanding
of bladder dysfunction in CES, both providers and patients
may be better prepared to manage long-term complications.
Supplementary materials
Supplementary material associated with this article can
be found in the online version at https://doi.org/10.1016/j.
spinee.2021.01.002.
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