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Cauda equina syndrome - healthcare professionals

Presentation of cauda equina syndrome (CES)

CES is a rare disorder affecting the bundle of nerve roots (cauda equina) at the lower (lumbar) end of the spinal cord and should be treated as a surgical emergency.

Click on the button below for a poster illustrating CES warning signs.  Poster: © Ruth Eaves, Medical Artists, Bolton NHS Foundation Trust 2023.

click here for poster

If patients with suspected CES do not seek immediate treatment to relieve the nerve root pressure, it may result in permanent paralysis, impaired bladder and/or bowel control, sexual dysfunction and neurogenic pain. Even with immediate treatment, some patients may not recover complete function. The best outcomes for CES occur with early treatment.

There is a recognised Suspected cauda equina syndrome pathway.


Causes of CES

Disc herniation

Road traffic accident, fall from height, penetrating injuries – gunshot, stabbing.

Primary – ependymoma, neurofibroma, meningioma; secondary metastasis .  In metastatic spinal cord compression, often the primary may be breast, prostate, melanoma or lung.

Meningomyelocoele, congenital dermoid sinus, congenital midline tumours: dermoid, epidermoid, teratoma, lipoma.

Infectious: neurosarcoidosis, schistosomiasis, abscess formation
Degenerative: central disc prolapse
Vascular: arteriovenous malformations
Latrogenic: anaesthetic, orthopaedic and neurosurgical procedures, lumbar arachnoiditis following radiculogram

Investigation of CES damage

Investigations are carried out to make a diagnosis, plan therapeutic intervention or follow progression and allow a prognosis to be made.

Radiological Investigations
Suspected CES should be treated as an emergency and assessed in A&E. An MRI scan should be carried out within 4 hours of admission to A and E, following the onset of cauda equina symptoms, and assessed by a Neurosurgeon.

Urological Investigations
The predominant urological symptom in patients with CES is of voiding difficulty. Patients report reduced flow, double and incomplete voiding and in severe cases complete retention with overflow incontinence.

A simple post void ultrasound scan can demonstrate whether there is incomplete emptying of the bladder, leaving residual urine.

Investigation of sexual dysfunction

In cases of CES, there is rarely a need to perform specific tests of sexual function. Men may report loss of erectile function and altered sensation, while women may also report loss of sensation in the genital area.

In men, it is important to demonstrate that pharmacologically induced erection is possible (with intracavernous injection or transurethral application of prostaglandin E1). This rules out a vascular cause for the underlying pathology and can also be used as a useful therapeutic intervention. It would be appropriate to trial a Phosphodiesterase-5 (PDE5) inhibitor, like Sildenafil (Viagra) , Tadalafil (Cialis).

Useful resources

Download our leaflet about CES

GIRFT guidance on use of the CES pathway

The Society of British Neurological Surgeons

British Association of Spinal Surgeons 

Wheelchair provision

Cauda Equina Syndrome is a condition where many are still able to walk, either independently, or with the use of walking aids. Walking any distance may be limited and could cause significant fatigue, pain and limit independence. A wheelchair may help in many ways, but it is vital that the wheelchair fits the needs of the individual.

SIA , CESCI and The Wheelchair Alliance, have produced a template letter which can be downloaded and given to the GP to support them to outline the more specific information that can help to make the referral to the wheelchair services more effective. This should ensure that the most appropriate equipment is provided.

download template letter

You can also contact our support line on 0800 980 0501 or contact our specialist clinicians.