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Cauda Equina Syndrome

Checked: 23-02-2024 by 5 Rob Adams Next Review: 22-08-2024


Cauda equina syndrome (CES) is a serious spinal condition that requires immediate assessment, investigation, and treatment. If it is unrecognised or treatment is delayed, this may result in permanent loss of bladder and bowel function, loss of sexual function, and lower limb paralysis. Patients may continue to experience ongoing severe disability despite prompt treatment but, if it is treated before symptoms become severe, this can reduce the risk of permanent disability.

CES is due to acute or rapidly progressive compression of the nerves in the lumbar or sacral spinal canal. The most common cause is a large lumbar disc prolapse but can be due to rarer causes such as trauma, infection, tumour, or spinal/epidural anaesthetic

Patients with CES can present to clinicians throughout primary and secondary care and it is essential that there is rapid access to imaging to confirm the diagnosis. The gold standard investigation is MRI scanning.


Please see also the following pages:

Assessment in Primary Care

NHSE have published a GIRFT (Getting It Right First TIme)  interactive pathway illustrating best practice for clinicians caring for patients suspected of having Cauda Equina Syndrome (CES).

The link below is directed at clinicians working in primary and community care:


Send patients to A&E with suspected cauda equina syndrome. A patient presenting with back pain and/or sciatic pain with:

    • Saddle anaesthesia, perineal sensory alteration
    • New difficulty or inability to initiate micturition/painless urinary retention/new onset overflow incontinence
    • Change in sexual function
    • Altered bowel or bladder sensation
    • Inability to move bowels
    • Lax anal sphincter
    • Bilateral or progressive neurological deficit in the lower limbs
    • Bilateral sciatica

****Update February 2024 - There are currently ongoing discussions on pathways of care for patients with suspected CES. Any future updates will be published here.****


(1) Red flag symptoms and signs | Diagnosis | Sciatica (lumbar radiculopathy) | CKS | NICE

(2) Interactive pathway to help diagnose and treat Cauda Equina Syndrome without delay is now live - Getting It Right First Time - GIRFT

(3) National-Suspected-Cauda-Equina-Pathway-UPDATED-V2-October-2023.pdf (


Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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