What are the symptoms of cauda equina syndrome?

Please note, that the information within this article is not a substitute for professional medical advice or consultation. We’ve outlined the main symptoms within this article but for more details on some of the red flag symptoms of cauda equina syndrome, you may be interested in our article on what to do when a GP doesn’t warn you about the risks of CES.

Early detection of CES symptoms is crucial, to avoid poor long-term outcomes for patients.

Usually the earliest symptoms of cauda equina syndrome are symptoms of sciatica, taking the form of lower back pain, and leg pain, combined with loss of sensation and a feeling of weakness in the legs. Sciatic pain occurs due to the nerve being compressed or irritated, sometimes due to a herniated disk. Typically this starts with one leg (unilateral sciatica) but may spread to the other leg (bilateral sciatica).

Often sciatica can be episodic, and patients may suffer periodically over a long time without it progressing to anything more serious. However, in some cases sciatica may progress to cauda equina syndrome. As such it is important to understand the signs which indicate that this may be happening.

Other early symptoms of cauda equina syndrome include a feeling of pins and needles or numbness, also located in both legs.

The main symptoms which indicate the onset of cauda equina syndrome can be grouped into six main categories:

• Progression to bilateral sciatica
• Motor weakness in both legs
• Numbness or change of sensation
• Bladder or urinary symptoms
• Bowel symptoms
• Sexual function

Bilateral sciatica is much like sciatica except the pain caused by the sciatic nerve branches are pinched on both legs.

If a patient develops bilateral sciatica either as a new condition or having progressed from unilateral sciatica, it is a sign of impending cauda equina syndrome. Recent NHS pathway guidance (the GIRFT National Suspected CES Pathway, published in February 2023) states that this symptom requires urgent referral to the nearest musculoskeletal (MSK) triage service.

The new CES pathway enables clinicians to better diagnose and care for those with suspected Cauda Equina Syndrome.

Severe or progressive neurological deficit of both legs is a clear indication of impending cauda equina syndrome. This includes major motor weakness in the knee, ankle or foot. While motor or muscle weakness can be caused by things such as lack of exercise, ageing, muscle injury or pregnancy, the location of the reduced motor function will indicate the cause. If the leg muscles in particular are weak, this is a symptom of cauda equina.

Several types of numbness or change in sensation are indicators of CES. These include:

• Loss of feeling or pins and needles between your inner thighs or in your genitals
• Numbness in or around your back passage or buttocks
• A new or altered feeling when using toilet paper to wipe yourself

Changes when passing urine, alongside other bladder or urinary symptoms associated with CES, include:

• Increasing difficulty when trying to urinate
• Increasing difficulty when you try to stop or control your flow of urine
• Loss of sensation when passing urine
• Leaking urine or recent need to use pads
• Being unable to tell when your bladder is either full or empty

The following bowel symptoms may indicate that CES is present:

• Inability to stop a bowel movement or leaking
• Loss of sensation when passing a bowel motion

Certain abnormalities in sexual function are also signs that cauda equina is present, and can include:

• Change in ability to achieve an erection or ejaculate
• Loss of sensation in genitals during sexual intercourse

Cauda equina symptoms can appear suddenly without little warning or over time, so there is no clear pattern. For example, a severe disc herniation can lead to cauda equine syndrome within 10 hours.

However, acute CES symptoms that appear rapidly are a medical emergency. Acute CES is characterised by the rapid onset of any of the above symptoms within this article, including lower back pain, motor weakness and bladder dysfunction.

If you have symptoms which are consistent with a possible diagnosis of cauda equina syndrome you should seek emergency medical assistance, either with an emergency appointment at your GP, or a visit to your nearest A&E department. While cauda equina syndrome is not life-threatening, it does permanent damage to your body, which can affect your quality of life and your long-term health. Early intervention can mean the difference between a good outcome and lifelong disability.

The only effective treatment for CES is surgery. This operation is known as lumbar decompression surgery which involves spinal decompression. Spinal decompression relieves any pressure on the nerves in the cauda equina region at the base of the spine by removing whatever is causing the pressure. Once the pressure on the nerves is released, the nerves stop being damaged. However, if they have been compressed over a sustained period, the damage may be irreversible.

In some cases, a doctor may mistake CES symptoms for other things. These include:

• A herniated or ruptured disc in the lumbar area
• Spinal infections or inflammatory spinal conditions (such as ankylosing spondylitis)
• Osteoarthritis (a form of spinal arthritis)
• Lumbar spinal stenosis
• Congenital spine disorders such as scoliosis
• Spinal tumours
• Traumatic injuries such as a car accident or heavy impact

Early intervention is crucial, which is why a misdiagnosis or failure to recognise CES can lead to worse outcomes for patients.

According to Claire Thornber, Founder of the Cauda Equina Champions Charity, time is of the essence. This is because when patients are sent home or diagnosis is missed, cauda equina syndrome “can occur at any time and sometimes just turning in bed, or a sneeze will be the catalyst that sets the 24-hour clock ticking.”

As specialists in cauda equina claims, we understand first hand how devasting cauda equina syndrome can be for people and their loved ones. We speak with people who have experienced poor or negligent diagnosis (and in some cases even misdiagnosis) as their cauda equina syndrome is missed by a GP or other medical professional.

If you think you may have a claim for clinical negligence related to CES, visit our cauda equina compensation claims page. Our team can guide you through the process and will work to ensure you receive the compensation and rehabilitation you deserve.