Patient handout

Cauda Equina Syndrome

PRODUCTION

1. Your condition

This handout is for cauda equina syndrome. Your care team identified this based on: new bilateral leg pain / sciatica (nice ng59 2016/2024; todd br j neurosurg 2017 pmid 28637110).

Other reasons your team may use this plan: perineal / saddle anaesthesia or paraesthesia (lavy bmj 2009 pmid 19336488; bass germon spine j 2015 pmid 25708139); new urinary retention with overflow / bladder-emptying difficulty (bass germon 2015 pmid 25708139); new faecal incontinence or loss of anal-sphincter tone (lavy bmj 2009 pmid 19336488).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
straight_then_indwelling_catheterisation	straight catheter for residual then 16-Fr indwelling pending decompression	urethral	continuous	Decompress overdistended bladder; document residual volume; preserve detrusor function (BASS Germon 2015 PMID 25708139)

Plan: CES adjunct bundle — catheterisation, analgesia, MESCC-overlay steroid, thromboprophylaxis, antiemetic (NICE NG59; BASS Germon Spine J 2015 PMID 25708139; Loblaw IJROBP 2012 PMID 22420969)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Complete painless urinary retention (CESR) with overflow incontinence + PVR usually >500 mL (BASS Germon Spine J 2015 PMID 25708139)(life-threatening)
Incomplete CES — urinary hesitancy / loss of awareness of bladder filling without complete retention; bilateral sciatica + saddle paraesthesia present (BASS Germon Spine J 2015 PMID 25708139)
Bilateral lower-limb progressive motor weakness (≥1 MRC grade drop over hours) — surgical emergency irrespective of bladder status (Quaile Int Orthop 2019 PMID 30374638)(life-threatening)
Large central/paracentral lumbar disc herniation (typically L4-L5 or L5-S1) causing cauda equina compression — most common phenotype (BASS Germon Spine J 2015 PMID 25708139)
Known active malignancy with new CES → metastatic epidural spinal cord compression overlay (Loblaw IJROBP 2012 PMID 22420969)(life-threatening)
CES on background of anticoagulation, antiplatelet therapy, or recent neuraxial procedure → epidural haematoma (BASS Germon Spine J 2015 PMID 25708139)(life-threatening)
CES with fever / IVDU / immunosuppression / recent procedure / indwelling vascular catheter → spinal epidural abscess (NICE NG59)(life-threatening)
Clinical features of CES (saddle change, urinary difficulty, bilateral sciatica) but MRI lumbosacral spine NEGATIVE for compression — scan-negative CES (Hoeritzauer Neurology 2020/21 PMID 33177221; Hoeritzauer J Neurol 2018 PMID 30298195)
Time from onset of red-flag symptoms to surgical decompression exceeding 48 h (Quaile Int Orthop 2019 PMID 30374638)
Absent perineal sensation and complete sphincter loss — "white flag" of LATE often-irreversible CES (Todd Br J Neurosurg 2017 PMID 28637110)(life-threatening)

5. Follow-up

Multidisciplinary rehab — urology (bladder retraining + ISC if persistent retention), colorectal (bowel programme), sexual health, physiotherapy, clinical psychology (post-CES distress + functional overlap), counselling on recurrence-from-stenosis prevention (NICE NG59; Quaile Int Orthop 2019 PMID 30374638)

6. Sources

Guideline: NICE NG59 Low back pain and sciatica in over 16s (2016, updated 2024) + UK British Association of Spine Surgeons (BASS) Standards of Care for Cauda Equina Syndrome (Germon Spine J 2015) + Todd 2017 red/white flags systematic review