From the Guidelines

Cauda Equina Syndrome (CES) is a rare but serious condition that requires prompt diagnosis and treatment.

CES is characterized by compression of the sacral and lumbar nerve roots within the vertebral canal, resulting in impairment of bladder, bowel, or sexual function and perianal or saddle numbness 1.
The most common cause of CES is lumbar disc herniation at the L4-L5 and L5-S1 levels, although other etiologies such as neoplasm, infection/inflammation, spinal stenosis, and hemorrhage can also occur 1.
Symptoms of CES may include low back pain, radicular symptoms, weakness in the lower limbs, sensory changes or numbness in the lower limbs, and absent lower limb reflexes 1.

The imaging study of choice for evaluating suspected CES is MRI lumbar spine without IV contrast, which can accurately depict soft-tissue pathology, assess vertebral marrow, and assess spinal canal patency 1.
CT lumbar spine without IV contrast can also be used to answer the question of whether or not cauda equina compression is present, although it is not as sensitive as MRI 1.
A focused history and physical examination should be performed to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement 1.

Clinicians should inquire about the location of pain, frequency of symptoms, and duration of pain, as well as any history of previous symptoms, treatment, and response to treatment 1.
The possibility of low back pain due to problems outside the back, such as pancreatitis, nephrolithiasis, or aortic aneurysm, or systemic illnesses, such as endocarditis or viral syndromes, should be considered 1.
Patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits, including motor deficits at more than 1 level, fecal incontinence, and bladder dysfunction 1.
The most frequent finding in CES is urinary retention, which has a sensitivity of 90% 1.

From the Research

Cauda equina syndrome (CES) is a rare syndrome characterized by a complex of symptoms and signs, including low back pain, unilateral or bilateral sciatica, motor weakness of lower extremities, sensory disturbance in the saddle area, and loss of visceral function, resulting from compression of the cauda equina 2.
CES can occur due to various conditions, including herniated lumbar discs, which is one of the most common causes, accounting for approximately 2% of cases 2.
Other causes of CES include ankylosing spondylitis, which can lead to chronic enthesitis of the vertebral column, initiating a process that results in dural stiffening and formation of ectasias, causing downstream nerve root damage 3.

The symptoms of CES can vary, but common presentations include low back pain, sciatica, motor weakness, sensory disturbance, and loss of bowel and bladder function 2, 4.
Diagnosis of CES can be challenging, and timely diagnosis is crucial to avoid permanent damage to the affected organs 5, 6.
A thorough history and physical exam, followed by magnetic resonance or computed tomography imaging myelogram, can aid in diagnosis and treatment 6.

Early diagnosis and treatment of CES are critical to optimize outcomes and minimize the risk of litigation 6.
Emergent spinal surgery referral, along with urgent decompression, is indicated once CES is suspected 6.
Even with expeditious surgery, improvements remain inconsistent, but early intervention has been shown to portend a greater chance of neurologic recovery 4, 6.
Long-term follow-up is essential to evaluate the real outcome of surgically managed CES, as short-term evaluation may be misleading about the residual capacity of late neurologic improvement 4.