What are the symptoms and treatment options for cauda equina syndrome?

Cauda Equina Syndrome: Symptoms and Treatment

Critical Symptoms Requiring Immediate Action

Cauda equina syndrome requires immediate emergency MRI and neurosurgical referral when red flag symptoms appear, as early intervention before complete syndrome with retention develops is critical to prevent permanent neurological damage. 1

Red Flag Symptoms (Early - Reversible Stage)

• Bilateral radiculopathy - bilateral radicular pain and/or bilateral sensory disturbance or motor weakness in the legs 1
• New difficulties with urination while still maintaining some control - any new change in bladder function is significant 1
• Subjective or objective loss of perineal sensation - though sensory testing is subjective and subtle impairment is easily missed 1
• Progressive neurological deficits in the legs 1
• Back and leg pain in typical lumbar nerve root distribution (sciatica) 1

White Flag Symptoms (Late - Often Irreversible Stage)

• Urinary retention or incontinence, especially painless retention (90% sensitivity for established CES) 1
• Fecal incontinence 1
• Complete perineal anesthesia 1
• Patulous anus 1

Diagnostic Algorithm

Do not wait for complete urinary retention before referral - this is a late sign indicating likely irreversible damage. 1

Physical Examination Findings

• Abnormal findings requiring immediate MRI: loss of perineal sensation, reduced voluntary rectal tone, or absent bulbocavernosus reflex 1
• A combination of normal bulbocavernosus reflex, voluntary rectal tone, and perianal sensation can effectively rule out CES 1
• Note that anal tone assessment has low interobserver reliability, especially among inexperienced clinicians 1

Imaging

• Immediate MRI is essential for all suspected cases and should be performed at the district general hospital as part of triage 1
• MRI confirmation rates are typically only 14-33%, with emergency surgery rates of only 4-7%, but this high true negative rate is necessary to achieve the lowest false negative rate 1
• No single symptom or sign has high positive predictive value; MRI confirmation is mandatory 1

Treatment Protocol

Emergency decompressive surgery is indicated for suspected CES with severe radiological compression and all cases of incomplete CES. 1

Timing of Surgery

• Better outcomes are associated with surgery within 12-72 hours of symptom onset compared to delayed surgery 1, 2
• Even with delayed presentation, surgical decompression can still result in significant improvement, though immediate intervention is always preferred 2
• Recovery of function is more likely if there is some preservation of perineal sensation preoperatively 2

Medical Management

• Steroids are NOT indicated or recommended in the emergency management of suspected CES 1

Prognosis Based on Timing

• Incomplete CES (CESI) treated early: patients typically achieve normal or socially normal bladder and bowel control 1, 2
• Complete CES with retention (CESR): variable recovery with 48-93% showing some improvement, but outcomes are significantly worse 1
• Urinary and fecal incontinence, catheter use, sexual dysfunction, and genital numbness are significantly more common in patients with CESR 3

Long-Term Outcomes

• At mean 5-year follow-up, 33% report bladder dysfunction with 10% requiring urinary catheter 3
• 38% have bowel dysfunction and 53% have sexual dysfunction 3
• 47% report genital numbness 3
• 67% report significant back pain, with 44% requiring further investigation 3
• 50% report moderate or worse depression 3
• 40% of working-age patients can no longer work due to CES-related problems 3
• Only a minority of patients with severe deficits return to work 1

Common Pitfalls to Avoid

• Waiting for complete urinary retention before referral - this is the most critical error 1
• Delaying MRI when CES is suspected 1
• Attributing early postoperative symptoms to common postoperative findings rather than developing CES 4
• Missing atypical presentations with isolated bladder-bowel involvement without motor weakness, which may present to urology rather than spine surgery 5