Cauda Equina Syndrome

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Cauda equina syndrome (CES) is a rare but serious condition that occurs when nerve roots in the lower spinal cord are squeezed or compressed, disrupting motor and sensory function in the bladder and lower extremities.

This cluster of nerve roots called the cauda equina (Latin for "horse's tail") sends and receives messages to the legs, bladder, and other parts of the body. CES can occur when a ruptured or herniated lumbar disc puts intense pressure on the cauda equina. If left untreated, CES can lead to serious and irreversible damage, such as chronic incontinence and paralysis of the legs. For this reason, symptoms of CES warrant immediate medical attention and, in many cases, emergency surgery.

This article discusses the symptoms, causes, diagnosis, and treatment of cauda equina syndrome, as well as ways to cope after treatment.

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What Are the First Signs of Cauda Equina Syndrome?

Symptoms of CES can come on acutely, in a matter of hours, or develop gradually over weeks or months. One of the first signs or most common symptoms is urinary retention (the bladder fills with urine, but you don't experience the normal sensation or urge to urinate).

Other symptoms of CES include:

  • Severe low back pain
  • Sciatica
  • Saddle anesthesia, which is numbness or other nerve sensory changes around the anus and the area of your body that sits (in a saddle)
  • Pain, numbness, or weakness in one or both legs
  • Sexual dysfunction that comes on suddenly
  • A loss of reflexes in the extremities
  • Loss of bowel control
  • Overflow urination (incontinence)

There are two stages of cauda equina syndrome based on urinary symptoms:

  • CES-Incomplete (CES-I): This is characterized by symptoms such as altered urinary sensation, loss of desire to void, poor urinary stream, and the need to strain to urinate.
  • CES-Retention (CES-R): Bladder control is completely lost.

What Causes Cauda Equina Syndrome?

The most common cause of CES is a ruptured or herniated disc in the lumbar area. Other possible causes may include:

  • Trauma or injury to the spine that leads to fractures or dislocations (gunshots, falls, auto accidents)
  • Tumors or infections that compress the cauda equina
  • Spinal stenosis, a narrowing of the spinal column that can be either congenital or acquired
  • Bone spurs in the spinal canal
  • Tuberculosis or Pott's paralysis
  • Iatrogenic side effects—injuries or illnesses that result from medical or surgical treatment
  • Spinal lesions or malignant tumors
  • Spinal infection, inflammation, hemorrhage, or fracture
  • Spinal arteriovenous malformations (AVMs)
  • Complications from lumbar spine surgery
  • Spinal anesthesia
  • Spinal birth defects

How Is CES Diagnosed?

Diagnosing cauda equina syndrome typically requires:

  • A medical history of symptoms, general health, and activity level
  • A physical exam to assess strength, reflexes, sensation, stability, alignment, and motion​

Testing may include:

  • Blood tests for infection
  • Magnetic imaging resonance (MRI), which yields three-dimensional images of the spinal cord, nerve roots, and surrounding areas
  • Myelography, a type of X-ray or computerized tomography (CT) imaging enhanced by the injection of a contrast material into the cerebrospinal fluid spaces that can show displacement on the spinal cord or spinal nerves
  • Specialized nerve testing such as nerve conduction velocity tests and testing electrical activity in muscles (electromyography)

Treatment for Cauda Equina Syndrome

The extent of urinary problems can determine how CES is treated.

A diagnosis of cauda equina syndrome usually is followed by emergency surgery within 24 to 48 hours. The goal is to relieve compression of the nerves. Moving swiftly is essential to prevent permanent complications such as nerve damage, incontinence, or leg paralysis.

Depending on the cause, high doses of corticosteroids also may be prescribed to reduce swelling. If an infection is found to be responsible for CES, antibiotics may be needed. For situations in which a tumor is the cause of CES, surgery to remove it may be necessary, followed by chemotherapy and/or radiation.

The outcome for people with CES-I at the time of surgery generally is favorable. Those whose CES has deteriorated to CES-R tend to have a poor prognosis.

Coping With CES

Even after surgery, CES can be a challenging condition to deal with. If bladder function has been impaired, recovery of bladder control may take time. It may be necessary to use a catheter or to wear disposable underwear. Frequent urinary infections are also a potential complication.

Loss of bladder or bowel control can be psychologically distressing, impacting social life, work, and relationships. Sexual dysfunction can also occur, contributing to relationship difficulties or depression. Talking with a mental health professional may be helpful.

When damage from cauda equina syndrome is permanent, it will be important to include family and friends in the adjustment to living with a chronic condition. Psychological counseling and/or a support group also can be helpful in this transition. Other specialists who can help include:

  • Occupational or physical therapist
  • Social worker
  • Continence advisor or physiotherapist
  • Sex therapist

Summary

Cauda equina syndrome is a rare condition where nerve roots in the lower spinal cord are compressed, which disrupts motor and sensory function in the bladder and lower extremities. The most common cause of CES is a ruptured or herniated disc in the lumbar area. Ideally, CES is treated with surgery within 24 to 48 hours of symptoms onset.

If you're having symptoms that could be CES, see a healthcare provider promptly. Delaying treatment can lead to permanent damage.

4 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. American Association of Neurological Surgeons. Cauda Equina Syndrome.

  2. Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J. 2011;20(5):690-7. doi:10.1007/s00586-010-1668-3

  3. Fairbank J, Mallen C. Cauda equina syndrome: implications for primary care. Br J Gen Pract. 2014 Feb;64(619):67-8. doi: 10.3399/bjgp14X676988

  4. OrthoInfo. Cauda eqina syndrome.

Additional Reading
  • Lavy C, James A, Wilson-MacDonald J. Cauda equina syndrome. BMJ. 31 Mar 2009. 338:b936. doi:10.1136/bmj.b936

By Anne Asher, CPT
Anne Asher, ACE-certified personal trainer, health coach, and orthopedic exercise specialist, is a back and neck pain expert.