Evaluation and management of cauda equina syndrome in the emergency department

Background: Cauda equina syndrome (CES) may be a devastating disease with the potential for significant patient morbidity. It is essential for emergency clinicians to be aware of how to effectively diagnose and manage this condition. Objective: This article provides a narrative review of the diagnosis and management of CES for the emergency clinician. Discussion: Cauda equina syndrome is a rare but emergent condition associated with back pain. It can result in severe morbidity and can be due to a variety of causes, most commonly vertebral disc protrusion. Diagnosis is often delayed, which may result in a poor prognosis. Red flags and findings consistent with CES include bilateral neurogenic sciatica, reduced perineal sensation, altered bladder function leading to painless urinary retention, loss of anal tone, and loss of sexual function. In isolation, history and examination findings demonstrate poor sensitivity. Symptoms may occur either suddenly or gradually, and most patients do not present with all of these symptoms. Postvoid bladder volume assessments can assist in the evaluation, but the diagnosis typically involves magnetic resonance imaging (MRI) or computed tomography myelography if MRI is not available. Treatment relies upon surgical consultation and operative intervention for decompression. Conclusion: Cauda equina syndrome can be a difficult diagnosis. However, knowledge of the history and examination findings, imaging, and treatment can assist the emergency clinician in optimizing management of this condition.