What is the diagnosis for Cauda Equina Syndrome (CES)?

From the Guidelines

Cauda equina syndrome should be diagnosed through a combination of clinical assessment and imaging studies, with urgent MRI of the lumbosacral spine being the gold standard imaging modality, as recommended by the most recent study 1. The diagnosis of cauda equina syndrome should be suspected in patients presenting with red flag symptoms including:

• Bilateral sciatica
• Saddle anesthesia
• Bowel or bladder dysfunction (particularly urinary retention)
• Lower extremity weakness or sensory deficits The diagnostic approach begins with a thorough neurological examination focusing on lower extremity strength, sensation (particularly in the perineal region), and reflexes. Key points to consider in the diagnosis and management of cauda equina syndrome include:
• Post-void residual bladder volume measurement is essential, with volumes exceeding 100-200 mL raising concern
• Urgent MRI of the lumbosacral spine is the gold standard imaging modality, as it can visualize compression of the cauda equina nerve roots
• If MRI is unavailable, CT myelography can be used as an alternative
• Laboratory tests including complete blood count, inflammatory markers, and urinalysis may help identify underlying causes such as infection
• Once diagnosed, cauda equina syndrome requires emergency neurosurgical consultation and typically urgent surgical decompression within 24-48 hours to prevent permanent neurological damage, as supported by the study 1. The timing of intervention is critical, as delays in diagnosis and treatment are associated with poorer outcomes including permanent bladder, bowel, and sexual dysfunction. It is essential to prioritize the diagnosis and management of cauda equina syndrome to prevent long-term morbidity and mortality, as emphasized by the study 1.

From the Research

Cauda Equina Syndrome Diagnosis

• Cauda equina syndrome is an uncommon but serious cause of lower back pain resulting from compression of the cauda equina nerve roots, most commonly by lumbar disc herniation 2.
• Red flag symptoms, such as bladder dysfunction, saddle anaesthesia, and sciatica, should lead to high clinical suspicion of cauda equina syndrome 2, 3, 4.
• Immediate magnetic resonance imaging (MRI) is crucial in patients with suspected cauda equina syndrome to allow prompt diagnosis and treatment 2, 3, 4.
• Urgent decompressive surgery is usually recommended for the best outcomes, to reduce morbidity and complication rates 2, 5.

Clinical Presentation and Evaluation

• Bilateral radiculopathy, perianal/perineal/saddle sensory disturbance, and bladder or bowel dysfunction are common red flags for cauda equina syndrome 3, 4.
• Radicular/sciatic pain, new motor weakness, and digital rectal examination (DRE) findings are also important considerations in the evaluation of cauda equina syndrome 3, 5.
• Postvoid residual measurement and DRE retain clinical significance in the assessment of cauda equina syndrome 3, 5.

Management and Treatment

• Surgical consultation and operative intervention for decompression are the primary treatments for cauda equina syndrome 2, 5, 4.
• The timing of surgery depends on the severity of symptoms and the presence of red flags, with emergency surgery recommended for patients with severe symptoms or significant neurological deficits 5.
• Complication, reoperation, and readmission rates are significant concerns in the postoperative period, with intraoperative dural tears, valvular heart disease, and fluid and electrolyte abnormalities identified as risk factors for readmission 6.