Evaluation and Management of Cauda Equina Syndrome


      Cauda equina syndrome is a potentially devastating spinal condition. The diagnosis of cauda equina syndrome lacks sensitivity and specificity, sometimes occurring after irreparable neurological damage has happened. Timely diagnosis and treatment is imperative for optimal outcomes and for avoiding medicolegal ramifications. Cauda equina syndrome results from conditions that compress the nerves in the lumbosacral spinal canal. Although no consensus definition exists, it generally presents with varying degrees of sensory loss, motor weakness, and bowel and bladder dysfunction (the latter of which is required to definitively establish the diagnosis). A thorough history and physical exam is imperative, followed by magnetic resonance or computed tomography imaging myelogram to aid in diagnosis and treatment. Once suspected, emergent spinal surgery referral is indicated, along with urgent decompression. Even with expeditious surgery, improvements remain inconsistent. However, early intervention has been shown to portend greater chance of neurologic recovery. All providers in clinical practice must understand the severity of this condition. Providers can optimize long-term patient outcomes and minimize the risk of litigation by open communication, good clinical practice, thorough documentation, and expeditious care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Germon T
        • Ahuja S
        • Casey ATH
        • Todd NV
        • Rai A
        British Association of Spine Surgeons standards of care for cauda equina syndrome.
        Spine J. 2015; 15(3 Suppl): 2S-4S
        • Gardner A
        • Gardner E
        • Morley T
        Cauda equina syndrome: a review of the current clinical and medico-legal position.
        Eur Spine J. 2011; 20: 690-697
        • Kostuik JP
        Medicolegal consequences of cauda equina syndrome: an overview.
        Neurosurg Focus. 2004; 16: e8
        • Spector LR
        • Madigan L
        • Rhyne A
        • Darden B 2nd
        • Kim D
        Cauda equina syndrome.
        J Am Acad Orthop Surg. 2008; 16: 471-479
        • Chau AM
        • Xu LL
        • Pelzer NR
        • Gragnaniello C
        Timing of surgical intervention in cauda equina syndrome: a systematic critical review.
        World Neurosurg. 2014; 81: 640-650
        • Todd NV.
        Cauda equina syndrome: is the current management of patients presenting to district general hospitals fit for purpose? A personal view based on a review of the literature and a medicolegal experience.
        Bone Joint J. 2015; (97-B): 1390-1394
        • Fraser S
        • Roberts L
        • Murphy E
        Cauda equina syndrome: a literature review of its definition and clinical presentation.
        Arch Phys Med Rehabil. 2009; 90: 1964-1968
        • McNamee J
        • Flynn P
        • O'Leary S
        • Love M
        • Kelly B
        Imaging in cauda equina syndrome—a pictorial review.
        Ulster Med J. 2013; 82: 100-108
        • Korse NS
        • Veldman AB
        • Peul WC
        • Vleggeert-Lankamp CLA
        The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome.
        PLoS One. 2017; 12e0175987
        • Olivero WC
        • Wang H
        • Hanigan WC
        • et al.
        Cauda equina syndrome (CES) from lumbar disc herniations.
        J Spinal Disord Tech. 2009; 22: 202-206
        • Rooney A
        • Statham PF
        • Stone J
        Cauda equina syndrome with normal MR imaging.
        J Neurol. 2009; 256: 721-725
        • Harrop JS
        • Hunt Jr, GE
        • Vaccaro AR
        Conus medullaris and cauda equina syndrome as a result of traumatic injuries: management principles.
        Neurosurg Focus. 2004; 16: e4
        • Lavy C
        • James A
        • Wilson-MacDonald J
        • Fairbank J
        Cauda equina syndrome.
        BMJ. 2009; 338: b936
        • Gleave JRW
        • Macfarlane R
        Cauda equina syndrome: what is the relationship between timing of surgery and outcome?.
        Br J Neurosurg. 2002; 16: 325-328
        • Srikandarajah N
        • Wilby M
        • Clark S
        • Noble A
        • Williamson P
        • Marson T
        Outcomes reported after surgery for cauda equina syndrome: a systematic literature review.
        Spine (Phila Pa 1976). 2018; 43: E1005-E1013
        • Suri P
        • Rainville J
        • Katz JN
        • et al.
        The accuracy of the physical examination for the diagnosis of midlumbar and low lumbar nerve root impingement.
        Spine (Phila Pa 1976). 2011; 36: 63-73
        • McCarthy MJ
        • Aylott CE
        • Grevitt MP
        • Hegarty J
        Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome.
        Spine (Phila Pa 1976). 2007; 32: 207-216
        • Ahn UM
        • Ahn NU
        • Buchowski JM
        • Garrett ES
        • Sieber AN
        • Kostuik JP
        Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes.
        Spine (Phila Pa 1976). 2000; 25: 1515-1522
        • Todd NV
        An algorithm for suspected cauda equina syndrome.
        Ann R Coll Surg Engl. 2009; 91 (author reply 359-360): 358-359
        • Todd NV
        • Dickson RA
        Standards of care in cauda equina syndrome.
        Br J Neurosurg. 2016; 30: 518-522
        • Thakur JD
        • Storey C
        • Kalakoti P
        • et al.
        Early intervention in cauda equina syndrome associated with better outcomes: a myth or reality? Insights from the Nationwide Inpatient Sample database (2005-2011).
        Spine J. 2017; 17: 1435-1448
      1. Kohles SS, Kohles DA, Karp AP, Erlich VM, Polissar NL. Time-dependent surgical outcomes following cauda equina syndrome diagnosis comments on a meta-analysis. Spine (Phila Pa 1976). 2004;29:1281-1287.

        • Hogan WB
        • Kuris EO
        • Durand WM
        • Eltorai AEM
        • Daniels AH
        Timing of surgical decompression for cauda equina syndrome.
        World Neurosurg. 2019; 132: e732-e738
        • Daniels AH
        • Ruttiman R
        • Eltorai AEM
        • Depasse JM
        • Brea BA
        • Palumbo MA
        Malpractice litigation following spine surgery.
        J Neurosurg Spine. 2017; 27: 470-475
        • Daniels EW
        • Gordon Z
        • French K
        • Ahn UM
        • Ahn NU
        Review of medicolegal cases for cauda equina syndrome: what factors lead to an adverse outcome for the provider?.
        Orthopedics. 2012; 35: e414-e419