What are your standards for Cauda Equina Syndrome?

Cauda Equina Syndrome is rare but it is one of the most serious conditions we are likely to come across in clinic and missing or delaying this diagnosis can have life-changing consequences.

Question and Safety Net

Always screen back pain patients for bowel and bladder and sexual function changes and saddle anasthesia. There is a need to be really clear about what symptoms you are looking for – difficulty going, difficulty stopping, going without realising, knowing when you have stopped. Numbness in a saddle distribution is also a key symptom. Some very helpful summary cards have been produced listing warning signs which you can go through with patients and give a copy to patients to ‘safety net’ so they know what symptoms to look out for and action to take. Cards are available here in many languages.


You should make a clear record of what you have asked patients and information and action advice that you have given patients.


If you suspect Cauda Equina an emergency referral should be made to A+E. It is good practice to find out your local pathway for referral – just google cauda equina and your county or Clinical Commissioning Group. Some areas may wish you to contact the Orthopaedic department and give prior warning of the referral.

Bilateral leg symptoms?

During 2019 there was some debate about the course of action to take for bilateral leg symptoms stimulated by a White Paper by Connect Health. (You can read more in this article.) Should you always refer or is there a more reasoned course of action? The suggested position was:

  • Bilateral leg pain with normal neurology, normal neurodynamic tests and no other CES symptoms- treat as per symptoms and monitor progress. Safety net with CES card or similar.
  • Bilateral leg pain with normal neurology, positive neurodynamic tests and no other CES symptoms- treat as per symptoms. Safety net with CES card or similar- if already had conservative treatment then may refer for scan on a routine basis (but not looking for CES)
  • Bilateral leg pain with abnormal neurology and normal/positive neurodynamic tests and no CES symptoms. Management depends on the degree of neurological deficit- if gross motor weakness or deteriorating neurology, then refer for an urgent scan ( but not same day) and safety net patient re CES.
  • Bilateral leg pain with any other CES symptoms- refer on for emergency scan

More information

If you want to read more, there is a summary of warning signs to look for in the NICE clinical knowledge summary on Sciatica.

There’s a really helpful podcast with Chris Mercer here.

How could you improve your practice – questioning about cauda equina symptoms and safety netting?

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