Review article| Volume 90, ISSUE 11, P1964-1968, November 2009

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Cauda Equina Syndrome: A Literature Review of Its Definition and Clinical Presentation


      Fraser S, Roberts L, Murphy E. Cauda equina syndrome: a literature review of its definition and clinical presentation.


      To review the current evidence for the signs and symptoms of cauda equina syndrome (CES).

      Data Sources

      Relevant literature sourced through Medline, Embase, and CINAHL using the key search words “cauda equina syndrome” combined with “definition,” “clinical presentation,” “signs and symptoms,” “pathology,” and “etiology.”

      Study Selection

      Not applicable.

      Data Extraction

      Not applicable.

      Data Synthesis

      Three reviewers independently extracted data on CES from the literature specific to its definition, clinical presentation, and etiology. Of 111 articles, 105 were included for review, and relevant information on CES was synthesized into a framework structured as per a clinical consultation. A content analysis was then conducted using the method adopted by the Chartered Society of Physiotherapy whereby the level of consensus for each sign and symptom of CES was determined by its percentage coverage within the literature: 100% coverage equals unanimity, 75% to 99% equals consensus, 51% to 74% equals majority view, and 0% to 50% equals no consensus. This enabled the frequency of each reported sign and symptom to be ranked. Articles that included specific definitions for CES were divided into 3 categories: those that (1) included generalized statements, (2) stated a pathomechanical basis, and (3) defined the syndrome by its clinical presentation. Throughout this review, the frequencies of specific etiologies and pathologies were noted. Together with details of clinical presentation, this enabled a comprehensive review of CES. No single aspect of CES within the literature achieved unanimity or consensus; however, a majority view indicated that there would be bladder and sensory disturbance (74% and 66% of all articles, respectively). The most commonly cited pathology resulting in CES was identified as the disk (45% of all articles reviewed).


      There are marked inconsistencies in the current evidence base surrounding the etiology and clinical presentation of CES, with 17 definitions identified. Subclassifications of the definition of CES are ambiguous and should be avoided. From reviewing 105 articles, a single definition of CES is proposed. For a diagnosis of CES, one or more of the following must be present: (1) bladder and/or bowel dysfunction, (2) reduced sensation in the saddle area, and (3) sexual dysfunction, with possible neurologic deficit in the lower limb (motor/sensory loss, reflex change).

      Key Words

      List of Abbreviations:

      CES (cauda equina syndrome)
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        • Tait M.J.
        • Chelvarajah R.
        • Garvan N.
        • Bavetta S.
        Spontaneous hemorrhage of a spinal ependymoma: a rare cause of acute cauda equina syndrome.
        Spine. 2004; 29: E502-E505
        • Kostuik J.P.
        • Harrington I.
        • Alexander D.
        • Rand W.
        • Evans D.
        Cauda equina and lumbar disc herniation.
        J Bone Joint Surg Am. 1986; 68: 386-391
        • Gleave J.R.
        • Macfarlane R.
        Cauda equina syndrome: what is the relationship between timing of surgery and outcome?.
        Br J Neurosurg. 2002; 16: 325-328
        • Markham D.E.
        Cauda equina syndrome: diagnosis, delay and litigation risk.
        Curr Orthop. 2004; 18: 58-62
        • Mercer C.
        • Jackson A.
        • Hettinga D.
        • et al.
        Clinical guidelines for the physiotherapy management of persistent low back pain: part 1: exercise.
        The Chartered Society of Physiotherapy, London2006 (20) (Accessed October 7, 2009)
        • Garcia J.
        Imaging of arthropathies and disorders of connective tissue.
        Curr Opin Radiol. 1991; 3: 737-745
        • Kerslake R.W.
        • Mitchell L.A.
        • Worthington B.S.
        Case report: CT and MRI of the cauda equina syndrome in ankylosing spondylitis.
        Clin Radiol. 1992; 45: 134-136
        • Lawrentschuk N.
        • Nguyen H.
        Cauda equina syndrome secondary to constipation: an uncommon occurrence.
        ANZ J Surg. 2005; 75: 498-500
        • Small S.A.
        • Perron A.D.
        • Brady W.J.
        Orthopedic pitfalls: cauda equina syndrome.
        Am J Emerg Med. 2005; 23: 159-163
        • Jensen R.L.
        Cauda equina syndrome as a postoperative complication of lumbar spine surgery.
        Neurosurg Focus. 2004; 16: e7
        • Brown K.L.
        Cauda equina syndrome: implications for the orthopaedic nurse in a clinical setting.
        Orthop Nurs. 1998; 17: 31-35
        • Storm P.B.
        • Chou D.
        • Tamargo R.J.
        Lumbar spinal stenosis, cauda equina, and multiple lumbosacral radiculopathies.
        Phys Med Rehabil Clin North Am. 2002; 13: 713-733
      1. Epidural hematoma: hospital not liable for spinal cord compression: court based its ruling on post-op nursing documentation.
        Legal Eagle Eye Newsl Nurs Prof. 2004; 12 (Accessed October 7, 2009.): 7
        • Mosdal C.
        • Iversen P.
        • Iversen-Hansen R.
        Bladder neuropathy in lumbar disc disease.
        Acta Neurochirurgica. 1979; 46: 281-286
        • Cooper A.B.
        • Sharpe M.D.
        Bacterial meningitis and cauda equina syndrome after epidural steroid injections.
        Can J Anaesth. 1996; 43: 471-474
        • Flores L.P.
        • Nascimento Filho Jde S.
        • Pereira Neto A.
        • Suzuki K.
        Prognostic factors related to gunshot wounds to the spine in patients submitted to laminectomy.
        ArqNeuropsiquiatr. 1999; 57: 836-842
        • Mangialardi R.
        • Mastorillo G.
        • Minoia L.
        • Garofalo R.
        • Conserva F.
        • Solarino G.B.
        Lumbar disc herniation and cauda equina syndrome: considerations on a pathology with different clinical manifestations.
        Chir Organi Mov. 2002; 87: 35-42
        • Tullberg T.
        • Isacson J.
        Cauda equina syndrome with normal lumbar myelography.
        Acta Orthop Scand. 1989; 60: 265-267
        • Caputo L.A.
        • Cusimano M.D.
        Atypical presentation of cauda equina syndrome.
        J Can Chiropr Assoc. 2002; 46: 31-38
        • Ziv T.
        • Watemberg N.
        • Constantini S.
        • Lerman-Sagie T.
        Cauda equina syndrome due to lumbosacral cysts in children.
        Eur J Paediatr Neurol. 1999; 3: 281-284
        • Kennedy J.G.
        • Soffe K.E.
        • Mcgrath A.
        • Stephens M.M.
        • Walsh M.G.
        • McManus F.
        Predictors of outcome in cauda equina syndrome.
        Eur Spine J. 1999; 8: 317-322
        • Loo C.C.
        • Irestedt L.
        Cauda equina syndrome after spinal anaesthesia with hyperbaric 5% lignocaine: a review of six cases of cauda equina syndrome reported to the Swedish Pharmaceutical Insurance 1993-1997.
        Acta Anaesth Scand. 1999; 43: 371-379
        • Grobler L.J.
        Back and leg pain in older adults: presentation, diagnosis, and treatment.
        Clin Geriatr Med. 1998; 14: 543-576
        • Deyo R.A.
        • Rainville J.
        • Kent D.L.
        What can the history and physical examination tell us about low back pain?.
        JAMA. 1992; 268: 760-765
        • Schmidt R.H.
        • Grady M.S.
        • Cohen W.
        • Wright S.
        • Winn H.R.
        Acute cauda equina syndrome from a ruptured aneurysm in the sacral canal: case report.
        J Neurosurg. 1992; 77: 945-948
        • Wipf J.E.
        • Deyo R.A.
        Low back pain.
        Med Clin North Am. 1995; 79: 231-246
        • Bartels R.H.
        • De Vries J.
        Hemi-cauda equina syndrome from herniated lumbar disc: a neurosurgical emergency?.
        Can J Neurol Sci. 1996; 23: 296-299
        • Carlson E.R.
        • Ord R.A.
        Vertebral metastases from oral squamous cell carcinoma.
        J Oral Maxillofac Surg. 2002; 60: 858-862
        • Shaw M.
        • Birch N.
        Facet joint cysts causing cauda equina compression.
        J Spinal Disord Tech. 2004; 17: 442-445
        • Hidalgo-Ovejero A.M.
        • Garcia-Mata S.
        • Gozzi-Vallejo S.
        • Izco-Cabezon T.
        • Martinez-Morentin J.
        • Martinez-Grande M.
        Intradural disc herniation and epidural gas: something more than a casual association?.
        Spine. 2004; 29: E463-E467
        • Lisai P.
        • Doria C.
        • Crissantu L.
        • Meloni G.B.
        • Conti M.
        • Achene A.
        Cauda equina syndrome secondary to idiopathic spinal epidural lipomatosis.
        Spine. 2001; 26: 307-309
        • Sylvester P.A.
        • Mcloughlin J.
        • Sibley G.N.
        • Dorman P.J.
        • Kabala J.
        • Ormerod I.E.
        Neuropathic urinary retention in the absence of neurological signs.
        Postgrad Med J. 1995; 71: 747-748
        • Paul G.
        • Engelbeen J.P.
        • Malghem J.
        • et al.
        Cauda equina syndrome in ankylosing spondylitis: report of four new cases and review of the literature.
        Rev Rhum Mal Osteoartic. 1991; 58: 527-534
        • Qureshi A.
        • Sell P.
        Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome.
        Eur Spine J. 2007; 16: 2143-2151