Red flag symptoms of cauda equina syndrome (CES): typically from a central PID
Usually severe LBP and bilateral neurogenic sciatica
Perineal/genital numbness
Inability to pass water since >6–8 h
Triage
CES: Incomplete—Emergency management!	CES-Retention: Urgent management!
Ideally surgery within 24 h of onset—good prognosis	Ideally surgery within 24 h of diagnosis: less good prognosis
Symptoms	Symptoms
Sciatica may be unilateral, bilateral or absent (L5/S1prolapse)—if present, is it increasing in intensity or becoming bilateral?	Sciatica: as for CES-I—NB Lumbar and sacral nerve roots may suffer progressive damage resulting in long term neuropathic leg pain/numbness
Perineal numbness: may be unilateral and patchy, becoming bilateral and spreading	Perineal numbness: as for CES-I but likely to be widespread and complete with diminishing discomfort
Neurogenic urinary dysfunction: HNPU>6 h loss of desire to void, poor stream, strain to micturate, sensation of full bladder	Neurogenic urinary dysfunction: HNPU >8 h painless urinary retention, overflow incontinence, no bladder sensation or control, faecal incontinence
Physical signs	Physical signs
Sciatica: check for neurological deficit in legs—SLR, reflexes, power and sensation. May be deteriorating and becoming bilateral	Sciatica: as for CES-I. May be more severe and bilateral with increased neurological deficit. May be absent or mild with sequestrated L5/S1 prolapse
Perineal numbness: usually incomplete—check light touch and pin-prick—always test for both	Perineal numbness: complete sensory deficit. Check light touch and pin-prick
Neurogenic bladder and bowel dysfunction: check anal sphincter tone (Deletion) and ‘wink’ reflex. Test trigone sensation—pull catheter gently	Neurogenic bladder and bowel dysfunction: painless full bladder, no anal sphincter function. No trigone sensation on pulling catheter

Action!

Immediately seek senior advice with a view to contacting a Spinal Surgery Team and arranging emergency MRI with transfer to a Spinal Surgery Unit if not available on site. Delay may cause further neurological damage!

By Alan Gardner, Edward Gardner, Tim Morley 2010