Cauda Equina Syndrome

Cauda equina syndrome (CES) requires rapid recognition and emergent decompression for optimal bladder, bowel, and motor outcomes. Diagnostic clarity can be clouded by overflow incontinence, analgesic use, and communication barriers; vigilance is paramount.

Clinical Criteria and Pitfalls

Red flags: urinary retention, saddle anesthesia, bilateral sciatica, progressive bilateral weakness, fecal incontinence.
Examine: post-void residual by bladder scan, anal tone, perianal sensation; document carefully.
Do not miss: severe central disc herniation, epidural abscess/hematoma, tumor, or fracture-retropulsion.

Imaging Examples

Lumbar MRI showing posterior epidural abscess compressing the thecal sac and cauda equina — CES due to posterior epidural abscess. Source: Wikimedia Commons (CC BY 4.0; © Chan & Oh).

Sagittal lumbar MRI with L4-L5 disc protrusion contacting L5 root — Large L4-L5 paramedian disc can precipitate CES if massive and central. Source: Wikimedia Commons (CC0).

Animated sagittal T2 MRI of lumbar spine — Animated T2 overview to contextualize multilevel degeneration. Source: Wikimedia Commons.

Lower limb dermatomes, anterior — Dermatomal reference for correlating sensory loss. Source: Wikimedia Commons (Public Domain).

Lower limb dermatomes, posterior — Posterior dermatomes highlighting sacral segments relevant to perineal sensation. Source: Wikimedia Commons (Public Domain).

Posterior view of lower limb nerves — Nerve map aid for lower motor neuron pattern recognition. Source: Wikimedia Commons (Public Domain).

Axial T2 lumbar MRI showing severe stenosis — Severe central stenosis can predispose to acute neurologic deterioration with superimposed disc or hematoma. Source: Wikimedia Commons (CC BY-SA 3.0).

Management and Timing

Emergent MRI and urgent decompression when CES suspected; do not delay for full labs unless sepsis suspected.
Broad-spectrum antibiotics prior to decompression if abscess; urgent drainage.
Document pre-op neurologic and bladder status; early catheterization for retention with post-op weaning plan.

Postoperative Course and Medico-legal Notes

Earlier surgery correlates with improved bladder outcomes; residual deficits common when presentation is delayed.
Maintain clear documentation of timing, counseling, and examination findings.

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