Cauda Equina Syndrome: An Overview

Medically Reviewed by Zilpah Sheikh, MD on January 24, 2024
7 min read

Cauda equina syndrome (CES) is a rare but serious disorder. It affects about 1 in every 65,000 people, with equal frequency across all genders. This condition occurs when something compresses your spinal nerve roots, called the cauda equina.

When you have it, it’s usually a surgical emergency, and any delays in treatment may result in irreversible disability. Lasting damage could lead to incontinence and possibly permanent paralysis of the legs.

Cauda equina is Latin for horse's tail. This bundle of nerve roots is located at the lower end of your spinal cord in the lumbosacral spine. The nerves send and receive messages to and from your legs, feet, and pelvic organs.

CES disease may either be acute or chronic.

Acute CES occurs when you suddenly start having serious CES symptoms and will need to get surgery in 24-48 hours.

It's chronic CES when you’ve had CES symptoms for an extended period before seeing a doctor, or when your CES symptoms continue after surgery and you have permanent nerve damage.

CES occurs more often in adults than in children. But, it can happen in children with a spinal congenital disability or those who've had a spinal injury.

These are the most common causes of CES:

  • A severe ruptured disk in the lumbar area (the most common cause)
  • Narrowing of the spinal canal (stenosis)
  • A spinal lesion or malignant tumor
  • A spinal infection, inflammation, bleeding, or fracture
  • A complication from a severe lumbar spine injury such as a car crash, fall, gunshot, or stabbing
  • A congenital disability, such as an abnormal connection between blood vessels (arteriovenous malformation)
  • Complications after a lumbar spine surgery
  • Spinal anesthesia
  • Spinal arteriovenous malformation (AVM), a condition where the blood vessels in or around the spinal cord form a tangle

It may be hard to diagnose CES. Symptoms vary and may come on slowly. They also mimic other conditions. If you have any of these symptoms, see your doctor right away:

  • Severe low back pain or pain in your legs (sciatica)
  • Pain, numbness, or weakness in one or both legs that causes you to stumble or have trouble getting up from a chair
  • Prickling, tingling, or burning in your lower limbs (paresthesia)
  • Loss of feeling or altered sensations in your legs, buttocks, inner thighs, backs of your legs, or feet that is severe or gets worse and worse; you may experience this as trouble feeling anything in the areas of your body that would touch a saddle if you were sitting on one (called saddle anesthesia)
  • Recent problems with bladder or bowel function, such as trouble eliminating urine or waste (retention) or trouble holding it (incontinence)
  • Sexual dysfunction that has come on suddenly
  • Abnormal reflexes or paralysis in your lower extremities

What are the first signs of cauda equina?

Some of the early symptoms of CES include:

  • Back and leg pain, weakness, numbness, or tingling
  • Trouble urinating completely or holding it
  • Difficulty with bowel movements, or being unable to hold it
  • Decreased sensation in the skin between your genitals and anus (perineum)
  • Difficulty with sex, such as problems having an orgasm or erection

CES is classified into complete and incomplete based on your urinary or bowel dysfunction symptoms. This classification determines the course of your treatment, too.

Complete cauda equina affects around 60% of people. In this case, you experience urinary and bowel incontinence and retention, meaning you have:

  • An inability to pee or poop (retention) or problems emptying your bladder completely
  • Can’t prevent yourself from peeing and pooping (incontinence)
  • Difficulty feeling sexual sensations

Incomplete cauda equina means you still have some control over your bladder and sexual functions, but you might be:

  • Losing the feeling that you need to poop or pee
  • Feeling an altered sensation of bladder fullness
  • Needing to strain when urinating
  • Having difficulty emptying your bladder

Incomplete CES occurs in 40% of cases.

Here's what a doctor may need to confirm a CES diagnosis:

  • A medical history, in which you answer questions about your health, symptoms, and activity
  • A physical exam to assess your strength, reflexes, sensation, stability, alignment, and motion. You may also need blood tests.
  • An MRI scan, which uses magnetic fields and computers to produce three-dimensional images of your spine
  • A myelogram -- an X-ray or a CT scan of the spinal canal after injection of contrast dye -- can pinpoint pressure on the spinal cord or nerves. This test is taken when an MRI scan is unavailable.
  • Anal muscle testing, which checks how well your rectal and anal muscles are working.
  • Electromyography (EMG), an electrodiagnostic test that checks muscle response to nerve stimulation
  • Nerve conduction studies (NCS), another electrodiagnostic test that checks nerve function and damage

If you have CES, you'll need immediate surgery to relieve pressure on nerves. This surgery is called lumbar laminectomy and must be done quickly to prevent permanent damage, such as paralysis of the legs, loss of bladder and bowel control, sexual dysfunction, or other problems. It’s best if surgery occurs within 48 hours of having symptoms.

Depending on the cause of your CES, you may also need high doses of corticosteroids. These can reduce inflammation and swelling along the spine. If an infection is the cause of your CES, you may get antibiotics. If a tumor is responsible, radiation or chemotherapy may be needed after surgery.

Depending on how much damage has occurred, even with treatment, you may not fully recover lower body function. If surgery is successful, you may continue to recover bladder and bowel function for years.

Medications your doctor may prescribe for bladder and bowel function include:

  • Hyoscyamine (Levsin)
  • Oxybutynin (Ditropan)
  • Tolterodine (Detrol)

Your doctor may also prescribe medications to manage pain, such as:

  • Drugs that change the way nerves handle pain, including antidepressants and anti-seizure medicines
  • Medications applied to the skin such as a capsaicin cream or lidocaine patch
  • Opioid analgesics

If permanent damage has occurred despite surgery, your CES becomes chronic. You'll need to learn how to adapt to your body's changes. You'll find that both physical and emotional support is essential.

Try to involve your family in your care. Many professionals can also support you. Depending on your limitations, you can seek help from:

  • An occupational or physical therapist
  • A social worker
  • A continence adviser and continence physiotherapist
  • A sex therapist
  • An emotional counselor or psychologist

And, as with many conditions, there may be nothing quite as helpful as support from those who really understand what you're going through. That's why joining a cauda equina support group may be a good idea.

If you have loss of bladder or bowel function, the following tips may help:

  • Use a catheter to completely empty your bladder three or four times a day.
  • Drink plenty of fluids and use good personal hygiene to prevent urinary tract infections.
  • Check for waste and clear the bowels with gloved hands. If needed, use glycerinsuppositories or enemas.
  • Wear protective pads and pants to prevent leaks.

It’s impossible to prevent CES, but you can reduce your risk of having a herniated disk, the most common cause of CES, by doing the following:

  • Avoid wearing high-heeled shoes, as they can misalign your spine.
  • Stop smoking, as tobacco products can weaken your disks.
  • Exercise regularly for stronger back and core muscles.
  • Lift objects with your knees bent and a straight back. Never bend from your waist.
  • Maintain a healthy weight to reduce pressure on your lower back.
  • Practice good posture to lessen the strain on your spine.
  • Stretch regularly, including after sitting for long periods.
  • Wear a safety belt at all times when in a vehicle.
  • Avoid contact sports.
  • Use safety equipment and harnesses on construction sites.
  • Wear a helmet and protective gear while riding bicycles and motorcycles.
  • Practice safety measures while using firearms.

CES is a serious condition that requires immediate surgery to keep the muscles and nerves in your lower body functioning. After surgery, you may need to work with various specialists to help you recover, do everyday activities and manage any physical or mental symptoms. You can reduce your risk of the most common cause of CES by keeping a healthy weight, using proper form when walking, lifting objects or exercising, and by following safety measures when doing activities that put you at risk of serious accidents.

What are three signs of cauda equina?

If you have any of the following symptoms, talk to your doctor:

What are the red flags of cauda equina syndrome?

You may have CES if you have these "red flag" symptoms:

  • Loss of feeling or altered sensations in your legs, buttocks, inner thighs, backs of your legs, or feet that is severe or gets worse and worse; you may experience this as trouble feeling anything in the areas of your body that would touch a saddle if you were sitting on one (called saddle anesthesia)
  • Severe low back pain or pain in your legs (sciatica)
  • Paralysis or weakness in your lower limbs
  • Urinary retention
  • Urinary or fecal incontinence
  • Trouble having sex

What does cauda equina pain feel like?

Cauda equina pain can feel like a burning sensation in your back and legs that doesn’t go away. You also may not be able to feel as much, since there can be a numbing sensation that affects your bladder, bowel, and genital areas.