Cauda equina syndrome - Revision history

Danbot: Strip excess bold text - keep only critical safety emphasis

2026-03-22T09:23:06Z

Strip excess bold text - keep only critical safety emphasis

← Older revision		Revision as of 09:23, 22 March 2026
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	==Clinical Features==		==Clinical Features==
	*'''Red flags''' (must screen for in any patient with [[Low back pain\|back pain]]):		*'''Red flags''' (must screen for in any patient with [[Low back pain\|back pain]]):
	**~~'''~~Urinary retention~~'''~~ or incontinence (most consistent finding; post-void residual >200 mL)		**Urinary retention or incontinence (most consistent finding; post-void residual >200 mL)
	**Fecal incontinence or decreased rectal tone		**Fecal incontinence or decreased rectal tone
	**~~'''~~Saddle anesthesia~~'''~~ (perineal/perianal numbness)		**Saddle anesthesia (perineal/perianal numbness)
	**Bilateral lower extremity weakness or radiculopathy		**Bilateral lower extremity weakness or radiculopathy
	**Progressive neurologic deficit		**Progressive neurologic deficit
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	==Evaluation==		==Evaluation==
	*~~'''~~MRI lumbar spine with and without contrast~~'''~~ — imaging modality of choice<ref name="frost">Fairbank J, Mallen C. Cauda equina syndrome: implications for primary care. ''Br J Gen Pract''. 2014;64(619):67-68. PMID 24567577.</ref>		*MRI lumbar spine with and without contrast — imaging modality of choice<ref name="frost">Fairbank J, Mallen C. Cauda equina syndrome: implications for primary care. ''Br J Gen Pract''. 2014;64(619):67-68. PMID 24567577.</ref>
	**Emergent MRI — do not delay for other workup		**Emergent MRI — do not delay for other workup
	**CT myelography if MRI unavailable or contraindicated		**CT myelography if MRI unavailable or contraindicated
	*~~'''~~Post-void residual~~'''~~ (bladder scan) — >200 mL supports diagnosis		*Post-void residual (bladder scan) — >200 mL supports diagnosis
	*~~'''~~Rectal exam~~'''~~ — assess sphincter tone (decreased in CES)		*Rectal exam — assess sphincter tone (decreased in CES)
	*Labs: CBC, ESR/CRP (if infection suspected), coagulation studies		*Labs: CBC, ESR/CRP (if infection suspected), coagulation studies

	==Management==		==Management==
	*~~'''~~Emergent neurosurgical or spine surgery consultation~~'''~~		*Emergent neurosurgical or spine surgery consultation
	*Surgical decompression within ~~'''~~24-48 hours~~'''~~ of symptom onset improves outcomes		*Surgical decompression within 24-48 hours of symptom onset improves outcomes
	**Earlier decompression (<24h) associated with better recovery of bladder function		**Earlier decompression (<24h) associated with better recovery of bladder function
	*If [[Epidural abscess\|epidural abscess]] suspected: blood cultures, IV antibiotics before imaging		*If [[Epidural abscess\|epidural abscess]] suspected: blood cultures, IV antibiotics before imaging
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	==Disposition==		==Disposition==
	*~~'''~~Admit~~'''~~ for emergent surgical evaluation		*Admit for emergent surgical evaluation
	*Do NOT discharge patients with suspected CES — missed diagnosis carries significant medicolegal risk<ref name="todd">Todd NV. Cauda equina syndrome: the timing of surgery probably does matter. ''Br J Neurosurg''. 2005;19(4):301-306. PMID 16455534.</ref>		*Do NOT discharge patients with suspected CES — missed diagnosis carries significant medicolegal risk<ref name="todd">Todd NV. Cauda equina syndrome: the timing of surgery probably does matter. ''Br J Neurosurg''. 2005;19(4):301-306. PMID 16455534.</ref>

Danbot: Major expansion: red flags, evaluation, management, peer-reviewed references

2026-03-21T18:30:35Z

Major expansion: red flags, evaluation, management, peer-reviewed references

← Older revision		Revision as of 18:30, 21 March 2026
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	==Background==		==Background==
	~~[[File:Gray662.png\|thumb\|Cauda~~ equina ~~and filum terminale seen from behind. The dura mater has been opened and spread out~~, ~~and the arachnoid mater has been removed.]]~~		*Compression of the cauda equina nerve roots (below the conus medullaris, typically L1-L2)
	*~~The cauda equina~~ (~~Latin for "horse's tail"~~) ~~begins at the 2nd Lumbar space extending down to the beginning of the sacral nerves. It is distal to the tapered end of the spinal cord, or conus medularis.~~<ref>~~Cohen MS, Wall EJ, Kerber CW~~, et al. ~~The Anatomy~~ of ~~the Cauda Equina on CT Scans and MRI~~. ~~J Bone Joint Surg Br 1991~~; 73 (3): ~~381~~-84.</ref>		*A '''surgical emergency''' — delayed treatment (>48 hours) associated with permanent neurologic deficit<ref name="ahn">Ahn UM, et al. Cauda equina syndrome secondary to lumbar disc herniation: a meta-analysis of surgical outcomes. ''Spine''. 2000;25(12):1515-1522. PMID 10851100.</ref>
			*Most common cause: large central [[Lumbar disc herniation\|lumbar disc herniation]] (70%)
	{{Epidural ~~compression syndromes types}}~~		*Other causes: spinal [[Epidural abscess\|epidural abscess]], tumor, [[Epidural hematoma\|spinal epidural hematoma]], spinal stenosis

	==Clinical Features==		==Clinical Features==
	[[~~File:Saddle anesthesia.png\|thumb~~\|~~Approximate area of "saddle anesthesia" seen from posterior (yellow highlight).~~]]		*'''Red flags''' (must screen for in any patient with [[Low back pain\|back pain]]):
			**'''Urinary retention''' or incontinence (most consistent finding; post-void residual >200 mL)
	*~~Most common in young men<ref>Rider LS, Marra EM. Cauda Equina And Conus Medullaris Syndromes. In: StatPearls. StatPearls Publishing~~; ~~2023. Accessed March 29, 2023. http://www.ncbi.nlm.nih.gov/books/NBK537200/</ref~~>		**Fecal incontinence or decreased rectal tone
	*~~The onset of perineal~~ anesthesia associated with bladder dysfunction is typical of the start of cauda equina syndrome and the time at which the clock starts on diagnosis and management.<ref>Quaile A. Cauda equina syndrome-the questions. Int Orthop. 2019;43(4)~~:957-961. doi:10.1007/s00264-018-4208-0</ref>~~		**'''Saddle anesthesia''' (perineal/perianal numbness)
	*~~The most common presenting symptom is urinary retention with~~ or ~~without resultant overflow urinary incontinence.~~		**Bilateral lower extremity weakness or radiculopathy
	**~~Painless urinary retention often has the greatest predictive value as a stand-alone symptom,~~ but it is unfortunately indicative of late, often irreversible cauda equina syndrome<ref>Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. Br J Neurosurg. 2017;31(3):336-339. doi:10.1080/02688697.2017.1297364</ref>		**Progressive neurologic deficit
	~~{{Epidural compression syndromes clinical}}~~		**Sexual dysfunction
			*[[Low back pain]] is present in most cases but may be minimal
			*Bilateral [[Sciatica\|sciatica]] is more concerning than unilateral
			*Decreased ankle reflexes bilaterally

	==Differential Diagnosis==		==Differential Diagnosis==
	~~{{Lower back pain DDX}}~~		*[[Conus medullaris syndrome]] (upper motor neuron signs, more symmetric)
			*[[Lumbar disc herniation]] without cauda equina involvement
	{{Spinal cord ~~syndromes DDX}}~~		*[[Spinal cord compression (non-traumatic)]]
			*[[Epidural abscess]]
			*[[Transverse myelitis]]
			*[[Guillain-Barré syndrome]]

	==Evaluation==		==Evaluation==
	~~[[File:~~MRI ~~of the~~ lumbar spine with ~~abscess in the posterior epidural space~~, ~~causing cauda~~ equina syndrome.~~jpg\|thumb\|~~MRI ~~of an abscess causing cauda equina syndrome.]]~~		*'''MRI lumbar spine with and without contrast''' — imaging modality of choice<ref name="frost">Fairbank J, Mallen C. Cauda equina syndrome: implications for primary care. ''Br J Gen Pract''. 2014;64(619):67-68. PMID 24567577.</ref>
	~~{{Epidural compression syndromes~~ diagnosis}}		**Emergent MRI — do not delay for other workup
			**CT myelography if MRI unavailable or contraindicated
			*'''Post-void residual''' (bladder scan) — >200 mL supports diagnosis
			*'''Rectal exam''' — assess sphincter tone (decreased in CES)
			*Labs: CBC, ESR/CRP (if infection suspected), coagulation studies

	==Management==		==Management==
	{{Epidural ~~compression syndromes~~ management}}		*'''Emergent neurosurgical or spine surgery consultation'''
	*~~Consider~~ [[~~dexamethasone~~]] 4 mg ~~q4 hours after first dose~~		*Surgical decompression within '''24-48 hours''' of symptom onset improves outcomes
			**Earlier decompression (<24h) associated with better recovery of bladder function
			*If [[Epidural abscess\|epidural abscess]] suspected: blood cultures, IV antibiotics before imaging
			*Pain management: [[NSAIDs]], [[acetaminophen]], [[opioids]] as needed
			*Foley catheter if urinary retention present
			*[[Dexamethasone]] 10 mg IV if tumor-related compression suspected

	==Disposition==		==Disposition==
	*Admit		*'''Admit''' for emergent surgical evaluation
			*Do NOT discharge patients with suspected CES — missed diagnosis carries significant medicolegal risk<ref name="todd">Todd NV. Cauda equina syndrome: the timing of surgery probably does matter. ''Br J Neurosurg''. 2005;19(4):301-306. PMID 16455534.</ref>

	==See Also==		==See Also==
	*[[Epidural ~~compression syndromes~~]]		*[[Low back pain]]
			*[[Spinal cord compression (non-traumatic)]]
			*[[Epidural abscess]]
			*[[Lumbar disc herniation]]

	==References==		==References==
	<references/>		<references/>

			[[Category:Neurology]]
	[[Category:Orthopedics]]		[[Category:Orthopedics]]
	~~[[Category:Neurology]]~~

Jrapa86: /* Clinical Features */

2023-03-30T04:26:33Z

Clinical Features

← Older revision		Revision as of 04:26, 30 March 2023
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	==Clinical Features==		==Clinical Features==
	[[File:Saddle anesthesia.png\|thumb\|Approximate area of "saddle anesthesia" seen from posterior (yellow highlight).]]		[[File:Saddle anesthesia.png\|thumb\|Approximate area of "saddle anesthesia" seen from posterior (yellow highlight).]]

			*Most common in young men<ref>Rider LS, Marra EM. Cauda Equina And Conus Medullaris Syndromes. In: StatPearls. StatPearls Publishing; 2023. Accessed March 29, 2023. http://www.ncbi.nlm.nih.gov/books/NBK537200/</ref>
			*The onset of perineal anesthesia associated with bladder dysfunction is typical of the start of cauda equina syndrome and the time at which the clock starts on diagnosis and management.<ref>Quaile A. Cauda equina syndrome-the questions. Int Orthop. 2019;43(4):957-961. doi:10.1007/s00264-018-4208-0</ref>
			*The most common presenting symptom is urinary retention with or without resultant overflow urinary incontinence.
			**Painless urinary retention often has the greatest predictive value as a stand-alone symptom, but it is unfortunately indicative of late, often irreversible cauda equina syndrome<ref>Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. Br J Neurosurg. 2017;31(3):336-339. doi:10.1080/02688697.2017.1297364</ref>
	{{Epidural compression syndromes clinical}}		{{Epidural compression syndromes clinical}}

	~~The most common presenting symptom is urinary retention with or without resultant overflow urinary incontinence.~~

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1: /* Background */

2020-11-11T19:45:19Z

Background

← Older revision		Revision as of 19:45, 11 November 2020
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	==Background==		==Background==
			[[File:Gray662.png\|thumb\|Cauda equina and filum terminale seen from behind. The dura mater has been opened and spread out, and the arachnoid mater has been removed.]]
	*The cauda equina (Latin for "horse's tail") begins at the 2nd Lumbar space extending down to the beginning of the sacral nerves. It is distal to the tapered end of the spinal cord, or conus medularis.<ref>Cohen MS, Wall EJ, Kerber CW, et al. The Anatomy of the Cauda Equina on CT Scans and MRI. J Bone Joint Surg Br 1991; 73 (3): 381-84.</ref>		*The cauda equina (Latin for "horse's tail") begins at the 2nd Lumbar space extending down to the beginning of the sacral nerves. It is distal to the tapered end of the spinal cord, or conus medularis.<ref>Cohen MS, Wall EJ, Kerber CW, et al. The Anatomy of the Cauda Equina on CT Scans and MRI. J Bone Joint Surg Br 1991; 73 (3): 381-84.</ref>

Rossdonaldson1: /* Evaluation */

2020-10-24T11:37:28Z

Evaluation

← Older revision		Revision as of 11:37, 24 October 2020
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	==Evaluation==		==Evaluation==
			[[File:MRI of the lumbar spine with abscess in the posterior epidural space, causing cauda equina syndrome.jpg\|thumb\|MRI of an abscess causing cauda equina syndrome.]]
	{{Epidural compression syndromes diagnosis}}		{{Epidural compression syndromes diagnosis}}

Rossdonaldson1: /* Clinical Features */

2020-10-24T11:36:23Z

Clinical Features

← Older revision		Revision as of 11:36, 24 October 2020
Line 5:		Line 5:

	==Clinical Features==		==Clinical Features==
			[[File:Saddle anesthesia.png\|thumb\|Approximate area of "saddle anesthesia" seen from posterior (yellow highlight).]]
	{{Epidural compression syndromes clinical}}		{{Epidural compression syndromes clinical}}

	The most common presenting symptom is urinary retention with or without resultant overflow urinary incontinence.		The most common presenting symptom is urinary retention with or without resultant overflow urinary incontinence.

	==Differential Diagnosis==		==Differential Diagnosis==

ClaireLewis at 00:09, 3 October 2019

2019-10-03T00:09:53Z

← Older revision		Revision as of 00:09, 3 October 2019
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	==Management==		==Management==
	{{Epidural compression syndromes management}}		{{Epidural compression syndromes management}}
	*Consider dexamethasone 4 mg q4 hours after first dose		*Consider [[dexamethasone]] 4 mg q4 hours after first dose

	==Disposition==		==Disposition==

Ermatt: Added most common presentation verbage.

2017-08-06T02:37:04Z

Added most common presentation verbage.

← Older revision		Revision as of 02:37, 6 August 2017
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	==Clinical Features==		==Clinical Features==
	{{Epidural compression syndromes clinical}}		{{Epidural compression syndromes clinical}}

			The most common presenting symptom is urinary retention with or without resultant overflow urinary incontinence.

	==Differential Diagnosis==		==Differential Diagnosis==

Mholtz at 22:34, 9 May 2017

2017-05-09T22:34:58Z

← Older revision		Revision as of 22:34, 9 May 2017
Line 17:		Line 17:
	==Management==		==Management==
	{{Epidural compression syndromes management}}		{{Epidural compression syndromes management}}
	*Consider 4 mg q4 hours after first dose ~~of dexamethasone~~		*Consider dexamethasone 4 mg q4 hours after first dose

			==Disposition==
			*Admit

	==See Also==		==See Also==

Kxl328: /* Management */

2017-05-06T17:48:29Z

Management

← Older revision		Revision as of 17:48, 6 May 2017
Line 17:		Line 17:
	==Management==		==Management==
	{{Epidural compression syndromes management}}		{{Epidural compression syndromes management}}
			*Consider 4 mg q4 hours after first dose of dexamethasone

	==See Also==		==See Also==