Intended for healthcare professionals

Clinical Review

Cauda equina syndrome

BMJ 2009; 338 doi: (Published 31 March 2009) Cite this as: BMJ 2009;338:b936
  1. Chris Lavy, honorary professor and consultant orthopaedic surgeon,
  2. Andrew James, specialist registrar,
  3. James Wilson-MacDonald, consultant spine surgeon,
  4. Jeremy Fairbank, professor of spine surgery
  1. 1Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford OX3 7LD
  1. Correspondence to: C Lavy christopher.lavy{at}

    Summary points

    • Cauda equina syndrome is rare, but devastating if symptoms persist

    • Clinical diagnosis is not easy and even in experienced hands is associated with a 43% false positive rate

    • The investigation of choice is magnetic resonance imaging

    • Once urinary retention has occurred the prognosis is worse

    • Good retrospective evidence supports urgent surgery especially in early cases

    • Litigation is common when the patient has residual symptoms

    An understanding of cauda equina syndrome is important not only to orthopaedic surgeons and neurosurgeons but also to general practitioners, emergency department staff, and other specialists to whom these patients present. Recognition of the syndrome by all groups of clinicians is often delayed as it presents with bladder, bowel, and sexual problems, which are common complaints and have a variety of causes. Patients may not mention such symptoms because of embarrassment or because the onset is slow and insidious.

    Cauda equina syndrome is a clinical area that attracts a high risk of litigation. Although symptoms have poor predictive value on their own for the syndrome, it is important to document the nature and timing of bladder, bowel, and sexual symptoms (along with any associated clinical findings), particularly if they are new, especially in those with a history of back pain and associated leg pain, and to make a timely referral for appropriate investigation and expert treatment.

    This review aims to highlight cauda equina syndrome as a possible clinical diagnosis, review the evidence for an emergency surgical approach, and maintain an awareness of the medicolegal issues that surround the condition.

    What is cauda equina syndrome and how common is it?

    Cauda equina syndrome results from the dysfunction of multiple sacral and lumbar nerve roots in the lumbar vertebral canal. Such root dysfunction can cause a combination of clinical features, but the term cauda equina syndrome is used only when these include impairment of bladder, bowel, or sexual …

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