Are you wondering what cauda equina syndrome is and its consequences? I often see patients in radiology wondering if the pain they are experiencing is cauda equina syndrome.
I will give you clear answers based on reliable scientific studies. I also consulted one of the doctors, a specialist in this condition for more insights.
Happy reading!😀 and feel free to ask questions in the comments or share your own experience.🙏
Last updated: June, 2025. Written by Juliet S, a diagnostic radiographer.
▶️Basic anatomy knowledge of the spine.
Our spine, also known as the backbone or vertebral column is a bony structure that supports our body and protects the spinal cord.
The spinal cord is a long, thin, tubular bundle of nervous tissues that extends from the brainstem down the spinal coccyx.
So, the cauda equina is a group of nerves and nerve roots stemming from the distal end of the spinal cord, typically levels lumbar vertebral (L1-L5).
Anatomy of the lower lumbar and sacral spine showing the cauda equina (image from Lavy 2009)
The nerves that originate from the cauda equina contain axons of nerves that give both motor and sensory innervation to the legs, bladder, anus, and perineum.
▶️Definition of cauda equina syndrome.
Cauda equina syndrome (CES) results from compression and disruption of the function of these nerves and can be extensive of the conus medullaris (terminal end of the spinal cord) when damage
One or more of these nerves may be affected.
⚪ Spinal nerves which originate at the lumbar level. L2, L3, L4, L5.
⚪Spinal nerves that originate from the sacrum called S1, S2, S3, S4, S5
⚪The coccygeal nerve at the coccyx level.
So, Cauda equina syndrome is a result of the compression of some or all these nerves
This is why you may see this sequence of letters and numbers on your examination medical report.
| Note!Such root dysfunction can cause a combination of clinical features. But the term cauda equina syndrome is used only when these include impairment of bladder, bowel, or sexual function, and perianal or “saddle” numbness. |
▶️Symptoms of cauda equina syndrome.
When you go to the doctors you will be asked the kind of symptoms you are experiencing before any examination, you may have a few of these.
Here are some of the symptoms often people complain about.
⚪Back pain which is sharp or chronic (with or without sciatic-type pains)
⚪Sensory changes or numbness in the lower limbs, buttocks and groin
⚪Lower limb weakness in the legs, difficulty walking or moving the legs.
⚪Reduction or loss of reflexes in the lower limb muscles
⚪Bladder dysfunction where you may have difficulty holding in urine, you wet yourself, you no longer have an erection.
⚪Bowel dysfunction
⚪Decreased sensation in the perineum
⚪Sexual dysfunction especially in men.
Source:Lavy,2009
Recent publications call into question the relevance of all these signs. Because only 32% of symptoms/signs are true “red flags,” indicating potentially avoidable damage (Todd,2017)
The clinical signals of cauda equina syndrome are very varied. They have no predictive value on the outcome.
This means that even if you have many intense symptoms, it doesn’t necessarily mean you will recover less well (Hawa 2023).
In 43% of cases, when faced with this type of clinical sign, a diagnosis of lumbar canal stenosis is made when the person does not have it (Hawa 2023).
▶️Who to consult for the diagnosis of cauda equina syndrome?
An understanding of cauda equina syndrome is important not only to orthopaedic surgeons and neurosurgeons but also to general practitioners, emergency department staff, and other specialists to whom you present.
Reason being there are other conditions that resemble it, such as simple sciatica.
And sometimes recognition of the cauda equina syndrome is often delayed as it presents with bladder, bowel, and sexual problems, which are common complaints and have a variety of causes.
Patients may not mention such symptoms because of embarrassment when being examined by the doctor.
That’s why, when faced with these signs that you find abnormal, it is important to consult your doctor. If your symptoms suggest cauda equina, your doctor will recommend:
▶️Different tests and imaging for proper diagnosis.
⚫MRI (magnetic resonance imaging) scan
Here in the United Kingdom magnetic resonance imaging (MRI) is the imaging modality of choice because it is better at showing soft tissues such as intervertebral disc, ligamentum flavum, dural sac, and nerve roots
⚫CT scan to look at your bones and to rule out any other issues such as fractures.
⚫You may be referred to a neurosurgeon or other specialist for further management.
Left: MRI scan showing compression of the cauda equina (arrow) due to a large posterior disc herniation at L4/5. Right: MRI scan showing a large disc herniation at L5/S1 (arrow) bulging posteriorly and compressing the cauda equina syndrome.
These additional examinations will allow
♦️To identify its cause.
♦️To confirm that it is indeed cauda equina syndrome.
When you come to x-ray, we are trained to perform imaging to rule out any issues such as fractures, lower back pain and cauda equina syndrome.
▶️Causes of equina syndrome?
The most common cause of compression in 45% of people diagnosed with cauda equina syndrome are:
⬜Herniated lumbar intervertebral disc
However having a herniated lumbar disc does not necessarily mean you have cauda equina syndrome. Most people have herniated discs but never experience any symptoms, not even lower back pain.
A retrospective review in Slovenia found an annual incidence of cauda equina syndrome resulting from intervertebral disc herniation of 1.8 per million population.
While in the USA, each year 0.12% of herniated discs are likely to cause equina syndrome.
But if these figures are even approximately correct then most UK general practitioners are unlikely to see even one true case caused by intervertebral disc herniation in their career (Lavy 2009).
Other causes that can trigger cauda equina syndrome include:
⬜Epidural abscess formation or bony involvement either within the spinal canal or impinging on it.
⬜Spinal manipulation in osteopathy, chiropractic or manual therapy.
⬜Spinal epidural hematoma.
⬜Infection
⬜Tumour (either metastatic or a primary CNS cancer).
⬜Trauma (particularly when there is retropulsion of bone fracture fragments).
⬜Spinal stenosis: the canal through which the spinal cord passes narrows, often due to osteoarthritis, a congenital issue, or aging,
⬜Aortic obstruction and cysts.
Source: Hawa,2023
Of all these, herniated disc is sighted out as the common cause of cauda equina syndrome but there are many other causes not listed here.
▶️What are the treatments for cauda equina syndrome?
This article will not review management of all the conditions leading to cauda equina syndrome, and some causes such as tumour clearly require detailed assessment of the nature and extent of the pathology.
However, surgery is the most common treatment for cauda equina syndrome depending on the cause of the syndrome, other treatments may also apply.
Surgical for cauda equina syndrome?
Once suspected, emergent spinal surgery referral is indicated to confirm the diagnosis and advance urgent decompression.
Reason being once detected early intervention has been shown to signify greater chance of neurologic recovery.
However, syntheses of recent studies have observed that: (Kogl 2024)
🟠Although surgery is generally recommended to treat cauda equina syndrome, some have argued that delaying surgery could be beneficial.
🟠There is very little data on the long-term outcomes, with or without treatment, for cauda equina syndrome.
Surgical planning normally focuses on the causes of cauda equina syndrome .This helps to widely decompress the area of automatic compression during surgery.
Physical therapy for cauda equina syndrome.
Physical therapy is a crucial component of recovery for individuals with Cauda Equina Syndrome particularly after surgical decompression.
Your physio will focus on restoring mobility, managing pain, improving strength and function, and addressing specific impairments like bladder and bowel dysfunction and foot drop
Pain management:
Using Therapies such as
🟠Cryotherapy (cold therapy)
🟠Thermotherapy (heat therapy)
🟠Transcutaneous Electrical Nerve Stimulation (TENS)
Will help manage pain and reduce muscle spasms in some people and they may not work for others. We all respond to treatment differently.
Strengthening exercises
🟠Gentle, controlled movements help maintain joint flexibility and prevent stiffness, tailored to the individual’s condition.
🟠Focus on building strength in the lower back, core, and legs to improve stability and function, including pelvic floor exercises for bladder and bowel control.
🟠Exercises to improve core muscle strength and stability, essential for spinal and postural control.
🟠Exercises that mimic daily activities to help you regain independence in tasks like standing, sitting, walking, and bending.
🟠 Bladder and bowel rehabilitation.
Osteopathy for cauda equina syndrome
Osteopathy can play a supportive role in managing symptoms associated with cauda equina syndrome
Osteopathy is a form of complementary medicine involving the treatment of medical disorders through the manipulation and massage of the skeleton and musculature.
An osteopath focuses on your whole body, including the soft tissues (such as muscles, ligaments and tendons), the spine and nervous system.
🟠It uses a variety of different hands-on methods, including Spinal manipulation. Soft tissue massage techniques.
Osteopaths are trained to recognize “red flags” that may indicate a serious condition like cauda equina syndrome and will refer you to a medical professional if necessary.
Osteopathic treatment can help with pain management, restoring mobility, and improving function after the initial medical treatment, but it should not be considered a substitute for surgery.
Exercises for cauda equina syndrome
Exercises for Cauda Equina Syndrome focus on regaining strength, flexibility, and balance, while also managing pain and improving nerve function
These exercises should be performed under the guidance of a physical therapist or other qualified healthcare professional.
There are many studies that evaluate doing certain types of physical exercises compared to doing nothing.
Some examples include:
🟠knee rolls and knee hugs.
🟠Cat-cow stretches, child’s pose.
🟠Bridge pose.
🟠Lumbar flexion.
🟠Side bends.
🟠Marching on the spot
There are no studies comparing the outcomes of people with or without physiotherapy in the diagnosis of cauda equina syndrome. However, there are some case studies.
It’s up to you to assess the benefits and constraints you derive from your physiotherapy sessions to decide whether to continue them or not.
In practice: do what brings you the most pleasure or well-being now and is least burdensome for you!
Orthotics, braces, heel lifts, proper footwear for cauda equina syndrome.
A pilot study that was done in the department of Physical Medicine and Rehabilitation, in India (Kurien,2020) Demonstrated that:
The use of a low heel lift on footwear as an alternative solution to improve walking ability of persons with cauda equina syndrome.
Suggested an increase of a 1 cm heel raise on walking performance of people with bilateral plantar flexor weakness following cauda equina syndrome.
Their explanation is that when the sacral nerve roots starting from S1 to S5 are affected, walking is often hindered due to:
🟠Excessive ankle flexion.
🟠Knee flexion during the support phase.
🟠Reduced ankle push at the beginning of the pre-swing phase.
To compensate for this, ankle-foot orthoses with an anterior stop set at 5° plantar flexion can be used, or heel lifts, which are easier to put in place and less aesthetically bothersome.
Here is an example of footwear with a heel lift. You can get them on Amazon or any store.
A Back strap footwear without heel lift. B Back strap footwear with 1 cm heel lift. (Image from Kurien,2020)
🟠The advantage of this footwear is that the straps around the ankle and the two dorsal straps provide better support & comfort for walking.
🟠They do not require conscious gripping as we do for slip-on model footwear.
If walking is very uncomfortable for you, this is an option you can try for a few days, as it is quite easy to implement.
You can make an improvised heel lift with what you have at home, buy one in a shoe or sports store, or on Amazon or another website.
This is not a treatment for the syndrome per say, it is simply compensation. Your occupational therapist can probably suggest other tricks of this kind personalised to your situation.
▶️ Recovery is possible from cauda equina syndrome?
The extent of recovery varies significantly depending on the severity and duration of nerve compression before treatment.
But recovery is possible from Cauda Equina Syndrome particularly with early and effective treatment, primarily through surgical decompression.
I completely understand that you may want to know precisely how and when you will recover.
However, be aware that the symptoms you have when the syndrome appears do not allow us to say whether you will recover and at what speed. A prognosis cannot be made based on these symptoms (Hawa 2023).
▶️Can cauda equina syndrome be cured?
Cauda Equina Syndrome can be cured if treated promptly with surgery to relieve pressure on the nerves, but the extent of recovery will vary from individual to individual.
If treatment is delayed, nerve damage can become permanent, leading to long-term issues like incontinence and mobility problems.
A study evaluated the recovery of people who had decompression surgery following cauda equina syndrome 6 to 23 years after the operation. Of the 46 people surveyed:
⚫37% had problems with urination
⚫47% had problems with defecation (bowel movements),
⚫55.9% had problems with sexuality.
These high figures are, of course, related to people of the same age who might also have concerns in these areas.
Nevertheless, these figures suggest that a complete recovery from sphincter and sexual disorders is still possible after cauda equina syndrome.
These people had also been evaluated 56 days after the operation. a larger proportion of them reported problems of this type, as shown in the table below:
Source: Korse ,2017
This means that one can continue to recover from urinary disorders several months or even years after the onset of symptoms and the operation for cauda equina syndrome.
▶️Does walking help cauda equina?
Walking is normally recommended by a medical professional for almost every surgery procedure not only cauda equina syndrome.
But it can be tiring, especially in the initial stages of recovery, you will be advised to rest until you feel you are ready to try walking.
With guidance from a medical professional, Walking can be beneficial for individuals with Cauda Equina Syndrome particularly after treatment.
This will depend on your ability to walk, and the level of benefit depends on the severity of the condition, the extent of nerve damage, and your individual circumstances.
Reasons why walking is beneficial when you have cauda equina syndrome.
Gentle walking can help maintain and improve the strength and mobility in your legs
⚫Improve balance and coordination, this can help you regain confidence through walking.
⚫In some cases, gentle walking and pelvic floor exercises can aid in regaining bladder and bowel control.
⚫Helps in blood circulation and avoid stiffness.
However, it is important to have a professional healthcare to guide with any exercise programme including walking because of the following reasons:
⚫The type, intensity, and duration of walking should be tailored to your individual specific needs and limitations.
⚫If walking gives you pain, then do not do it, always listen to your body and adjust activity accordingly.
⚫You can use walking aids such as canes, walkers, to help you move around and maintain balance.
▶️What is the life expectancy of someone with cauda equina syndrome?
There is little evidence in scientific studies about life expectancy of Cauda equina syndrome.
The truth is cauda equina syndrome does not directly affect life expectancy. It’s a condition that affects the nerves at the base of the spinal cord, but it doesn’t typically lead to a shortened lifespan
However, there can be long-term complications of cauda equina, such as:
🟣 Chronic pain: some people live with chronic pain the rest of their life, which normally improves with therapy.
🟣Mobility issues: if you are not mobile, always on bed rest, this can increase the risk of pressure sores, infections and cardiovascular problems.
🟣Bladder or bowel dysfunction which can lead to recurrent infections.
🟣Sexual dysfunction.
These can indirectly impact on your overall health and quality of life.
We have come to the end of this article and I hope I have answered some of your questions.
Any questions let’s meet in the comments sections. Wishing you a quick recovery!🙋.
You may also be interested in these articles.
⚫Acute lower back pain, how long does it last?
⚫How long does sciatic pain last?
📚Sources:
Rider LS, Marra EM. Cauda Equina and Conus Medullaris Syndromes. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537200/
Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda equina syndrome. BMJ. 2009 Mar 31;338:b936. doi: 10.1136/bmj.b936. PMID: 19336488.
Todd NV. Guidelines for cauda equina syndrome. Red flags and white flags. Systematic review and implications for triage. Br J Neurosurg. 2017 Jun;31(3):336-339. doi: 10.1080/02688697.2017.1297364. Epub 2017 Mar 2. PMID: 28637110.
Hawa A, Denasty A, Elmobdy K, Mesfin A. The Most Impactful Articles on Cauda Equina Syndrome. Cureus. 2023 Apr 24;15(4):e38069. doi: 10.7759/cureus.38069. PMID: 37228568; PMCID: PMC10208163.
Korse NS, Veldman AB, Peul WC, Vleggeert-Lankamp CLA. The long term outcome of micturition, defecation and sexual function after spinal surgery for cauda equina syndrome. PLoS One. 2017 Apr 19;12(4):e0175987. doi: 10.1371/journal.pone.0175987. PMID: 28423044; PMCID: PMC5397048.
Kögl N, Petr O, Löscher W, Liljenqvist U, Thomé C. Lumbar Disc Herniation—the Significance of Symptom Duration for the Indication for Surgery. Dtsch Arztebl Int. 2024 Jun 28;121(13):440-448. doi: 10.3238/arztebl.m2024.0074. PMID: 38835174; PMCID: PMC11465477.
Kurien AJ, Senthilvelkumar T, George J, Kumar V, Rebekah G. Heel lift improves walking ability of persons with traumatic cauda equina syndrome-a pilot experimental study. Spinal Cord Ser Cases. 2020 Mar 17;6(1):16. doi: 10.1038/s41394-020-0266-9. PMID: 32184382; PMCID: PMC7078180.