Updated perspective: STAT surgery for significant cauda equina syndromes.

Background: For over a decade, STAT surgery has been the standard of care (SOC) for treating significant cauda equina syndromes (CES). Nevertheless, too many spinal surgeons, physician extenders, and other medical professionals still wrongly believe they have up to 24-48 hours to treat CES. Methods: To counter this misconception, we reviewed the evolution of treatment for significant CES from the outdated dominant protocols of < 48 h, to 24 - < 48 h, to < 24 h, to 0-< 24 h, to the present SOC; STAT, "prompt", surgery performed "the sooner the better". Results: A 2014 study found that there is no support in the literature for delaying CES surgery for up to 48 h, and further; "... the earlier the surgical intervention, the more beneficial the effect for compressed nerves." Subsequent studies advocated for < 24 h for early CES, finding they resulted in improved outcomes including bladder function especially for those with incomplete/partial (ICES) vs. total/retention CES (RCES). One study, involving 20,924 CES patients, showed the best improvement for surgery performed within 0 - < 24 h, leading to the present SOC for treating significant CES, as STAT or "the sooner the better". Conclusion: Based on the up-to-date literature, the present SOC for managing significant CES is STAT surgery. Notably, the American Association of Neurological Surgeons (AANS) "guidelines" (published 4/5/24 on (www. aans.org)) cited the present treatment for CES; "Prompt surgery is the best treatment for patients with CES;" with the Merriam-Webster definition of prompt as "immediate" or "without delay". We agree that the present SOC for treating significant CES is STAT or "prompt" surgery.