Cauda Equina Syndrome Red Flag Symptoms For Patients

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Acute Cauda Equina Syndrome is a Medical Emergency that requires timely diagnosis and treatment to reverse or stop the worsening of neurological damage to the spinal nerve roots (the nerves in the low back). Please seek Emergency Medical Evaluation immediately if you are experiencing the RED FLAG symptoms of Cauda Equina Syndrome. If diagnosis and/or treatment is delayed it can lead to sexual dysfunction, chronic pain, leg weakness, foot weakness, severe spasms, leaking or uncontrollable bladder/bowels, numbness, and paralysis. Do not wait and see, get evaluated by an emergency medical professional if you have any of the following red flag symptoms:
Note: Not all individuals have every symptom if you have one or more symptoms, get emergency medical attention.
  • Saddle Anesthesia
    • Decreased sensation anywhere in one's legs, pelvic area or bottom that would touch a saddle while sitting on a horse
    • If one cannot feel oneself wipe, or it feels different their pelvic region or bottom when using the restroom 
    • Having decreased sensation in this area, but it is not totally numb, is a RED FLAG Symptom
    • Complete loss of sensation in this region with urinary and/or bowel incontinence is a White Flag Symptom (still seek emergency medical evaluation).
  • Bladder and/or Bowel incontinence or hesitancy
    • Incomplete Cauda Equina Syndrome (CES-I) causes individuals to have difficulty starting flow, maintaining flow, and in some cases, they cannot start urinary flow at all; urinary hesitancy. This can cause urinary retention. 
    • Inability to feel oneself urinate or defecate.
    • Complete Cauda Equina Syndrome (CES-C), individuals lose complete control of their bladder and/or bowels, this is called incontinence. They may or may not know they had an accident due to decreased sensation in the area not letting them know they are soiled; this is a White Flag Symptom (still seek emergency medical evaluation). A White Flag symptom is a symptom in which the likelihood of recovery is diminished due to either severity of the injury, or more commonly, delay in care from missed Red Flag Symptoms. The phrase White Flag Symptoms arose from so many patients being misdiagnosed in the early stages and ending up in the Complete Cauda Equina Syndrome stage in which it is considered too late to reverse the damage; waving the white flag for surrender. There is hope, some individuals with Complete Cauda Equina Syndrome do show some recovery. 
  • Bilateral Leg Pain and/or Sciatica
    • pain in both legs, not unlike sciatica

    • radiating pain down the legs

  • Leg and/or Foot Weakness

    • Stumbling

    • Tripping over one's feet

    • Trouble with weight-bearing; unable to stand without falling or needing significant assistance to stand

    • Legs giving out

    • Difficulty with coordination

    • Loss or decreased reflexes

  • Severe Lower Back Pain​​​





Some cases of Cauda Equina Syndrome are slow onset and present slightly differently. Typically these cases are called CES-R, or high-risk of developing Cauda Equina Syndrome. The treatment of CES-R and CES-I is the same during the diagnosis phase (emergency MRI, pain management).  However, that is where the similarities end. CES-R may not require immediate treatment, that is dependent on the neurosurgeon. Some surgeons recommend close monitoring and/or physical therapy and pain management, while others will do surgery to prevent further compression of the cauda equina (CE). 
Once a patient has CES-I, it is imperative that treatment is started within 48 hours of onset of symptoms, NOT from the date of diagnosis. In this stage, early treatment leads to the highest probability of reversal of symptoms or the stoppage of worsening symptoms. Once a patient has CES-C (complete Cauda Equina Syndrome), it may be too late! Patients that have CES-C have the worst patient outcomes and rarely recover function, those that do have a recovery of incontinence usually are left with motor and sensory deficits. 
The optimum time to treat Cauda Equina Syndrome is during the CES-I stage. Do not wait for incontinence to treat Cauda Equina Syndrome. 
Those sent home with CES-R for treatment of back pain, please seek immediate medical attention if experiencing new or worsening Cauda Equina Syndrome RED FLAGS, see below for other slow-onset symptoms to watch for. 
  • Sexual Dysfunction
    • Men- Erectile dysfunction (inability to get an erection, inability to maintain an erection, inability to ejaculate)- if sudden in conjunction with back pain, seek emergency medical help.
    • Women- Decreased sensation, vaginal dryness (common in spinal injuries), vaginal prolapse (the vaginal wall loses its muscle tone and starts coming out of the vaginal canal, the uterus, bladder, urethra,  can also descend into and/or out of the vaginal canal, one may also develop anal prolapse) 
  • Decreased Sensation in one or both legs and/or feet
    • Unable to feel light touch, unable to feel the difference between hot and cold, unable to feel anything
  • Frequent constipation and/or leakage
  • Anal Prolapse 
    • This results from the decreased tone of the sphincter muscles in the anus, allowing for part of the lower intestines to protrude out.
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