Cauda Equina Syndrome

CES = compression of the cauda equina (usually large central disc L4/5–L5/S1). Red flags: bilateral leg symptoms, saddle anaesthesia, bladder dysfunction. Emergency MRI at presentation whatever the hour; incomplete CES (some bladder function) is the…

CES Emergency Pathway

The pathway

1 · Ask the questions

Bilateral sciatica/weakness?
Saddle numbness — wiping changed?
Bladder: urge lost, retention, incontinence?
Bowel + sexual function

2 · Examine completely

Lower limb neuro (often asymmetric)
Perianal sensation S2–4, light touch + pinprick
PR: anal tone + squeeze
Post-void bladder scan

3 · Emergency MRI

At presentation — tonight, whatever the hour
No overnight MRI on site → transfer
X-ray/CT cannot exclude CES

4 · Refer immediately

Spinal surgery / neurosurgery with images
CES-Incomplete → emergency decompression
CES-Retention: still urgent, worse prognosis

5 · While awaiting theatre

Catheterise retention, monitor
Analgesia, NBM, VTE assessment
Serial neurology + times documented

6 · Safety-net everyone else

Discharged back pain → written CES red-flag advice
Early CES can be unilateral — return instructions explicit

Drugs

Drug	Dose	Route	Notes
Analgesia (multimodal)	Paracetamol + opioid titrated	PO/IV	Severe pain; avoid masking neurological change with excess sedation.
NO role: corticosteroids	—	—	Disc CES gains nothing from steroids (unlike MSCC — dexamethasone there).
VTE prophylaxis	Mechanical initially	—	Pharmacological per surgical team once theatre plan clear.

When to escalate

Any saddle/bladder red flag — MRI tonight, no deferral,Deteriorating neurology while waiting — inform spinal team immediately,Cancer history — treat as possible MSCC: dexamethasone + oncology pathway,No MRI capability — immediate transfer, document times

Reference: GIRFT/BASS National CES Pathway 2023 / NICE NG59

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.