Cauda equina syndrome

Cauda equina syndrome (CES) is caused by compression of the lumbosacral nerve roots of the cauda equina. It is a neurosurgical emergency; delays in diagnosis and/or surgical treatment may result in permanent, life-changing motor and sensory disabilities including lower limb paralysis and loss of bladder, bowel, and sexual function.

Almost all patients with CES have sciatica and back pain at presentation. Red-flag features for CES, which may be subtle in the early stages, include: bladder dysfunction (e.g., difficulty starting or stopping urination, impaired sense of urinary flow); altered sensation in the perianal, perineal, or genital ('saddle') areas; bowel dysfunction (e.g., loss of sensation of rectal fullness); motor weakness affecting both legs; sexual dysfunction. Urinary retention or overflow incontinence and faecal incontinence are indicators of late-stage or severe CES.

Emergency magnetic resonance imaging (MRI) is essential in any patient with suspected CES.

If CES is confirmed by the combination of clinical features and MRI findings, emergency surgical decompression must be undertaken as soon as possible. Evidence suggests that loss of function in CES is a continuous process with a poorer outcome the longer the cauda equina nerve roots are compressed.

Cauda equina syndrome (CES) is caused by compression of the lumbosacral nerve roots that extend below the spinal cord. The most common cause is due to disc prolapse at the L4/5 or L5/S1 level and stenosis of the spinal canal. Less commonly, compression may be due to pathology in a higher disc, or to a tumour, infection, or trauma. Typical symptoms and signs of CES include leg pain and/or back pain, together with one or more of: bladder or bowel dysfunction; altered perianal, perineal, or genital sensation; motor weakness affecting both legs; and sexual dysfunction.

For diagnosis and management of compression associated with malignancy, see Malignant spinal cord compression.