Cauda Equina Syndrome with Retention (CESR) - Emergency Surgical Decompression Required
This patient has cauda equina syndrome with retention (CESR) and requires emergency MRI followed by immediate surgical decompression within 12 hours to prevent permanent neurological disability. 1
Clinical Classification and Prognosis
This presentation represents CESR (Cauda Equina Syndrome with Retention) based on:
- Bilateral leg weakness (3/5 hip flexion and leg extension) indicating bilateral radiculopathy 1
- Decreased perineal sensation (objective sensory loss in saddle distribution) 1
- Reduced rectal sphincter tone (indicating lower motor neuron dysfunction) 1
These are "white flag" features indicating late-stage, potentially irreversible cauda equina compression. 1 Patients treated at the CESR stage have severe long-term impairment with paralyzed, insensate bladder and bowel requiring intermittent self-catheterization, manual fecal evacuation, and usually no useful sexual function. 1 Only 48-93% show any improvement after surgery, and only a minority return to work. 1
Immediate Management Algorithm
Step 1: Emergency MRI (Within Hours)
- Obtain emergency MRI of the lumbosacral spine immediately to confirm severe cauda equina compression and identify the compressive lesion (typically central disc herniation). 1
- MRI is mandatory for diagnosis as clinical features alone cannot definitively diagnose CES, though this presentation is highly suspicious. 1
Step 2: Emergency Surgical Decompression
Operate within 12 hours of symptom onset if any perineal sensation or anal tone remains preserved. 1 The British Journal of Neurosurgery guidelines recommend emergency surgery (if resources permit) for CESR patients within 12 hours or for any CESR patient with some preservation of perineal sensation and/or anal tone. 1
Surgery timing is critical: While the evidence shows trends for better outcomes with surgery at 12-72 hours post-CESR compared to further delayed surgery, statistical significance is only achieved in 30% of comparisons. 1 However, earlier is definitively better - recovery of function is more likely if there is some perineal sensation preoperatively. 1
Step 3: Surgical Approach
- Standard decompressive laminectomy with discectomy to remove the compressive lesion 2
- The specific surgical technique depends on the pathology identified on MRI 2
Critical Pitfalls to Avoid
Do not delay imaging or surgery for additional workup. This is a neurosurgical emergency where hours matter for functional outcomes. 1
Do not catheterize the patient before assessment if possible, as this obscures whether the patient has progressed to urinary retention (CESR) or still maintains voluntary bladder control (CESI). 1 However, if the patient already has reduced anal tone and decreased perineal sensation, CESR is already present. 1
Do not mistake this for rectal prolapse or fecal impaction. The combination of bilateral leg weakness, perineal sensory loss, and reduced anal tone indicates neurological pathology, not anorectal pathology. 1 The anorectal emergency guidelines 1 are not applicable to this neurological presentation.
Expected Outcomes
Realistic counseling is essential: Even with emergency surgery, this patient faces high risk of permanent bladder, bowel, and sexual dysfunction given the late presentation with CESR. 1 Many patients require intermittent self-catheterization, bowel management programs, and have persistent neurological deficits. 1 The goal of emergency surgery is to prevent further deterioration and maximize whatever recovery potential remains. 1
If this patient had presented earlier (at the CESI stage with objective signs but preserved voluntary bladder control), outcomes would be dramatically better with typically normal or socially normal bladder and bowel control long-term. 1 This underscores why the "red flags" of bilateral radiculopathy, any bladder symptoms with preserved control, and subjective perineal sensory changes should trigger emergency evaluation before progression to CESR. 1