Beyond Recovery: Long-Term Multidomain Disability and the Satisfaction Paradox in Cauda Equina Syndrome

Long-term outcomes after cauda equina syndrome (CES) are commonly reported using isolated endpoints such as bladder recovery, which may underestimate the true burden of disease. CES affects multiple functional domains, yet its cumulative long-term impact remains poorly characterised.

To evaluate long-term outcomes after CES using a multidomain framework, quantify cumulative functional burden, examine discordance between residual deficits and patient-perceived recovery, and identify factors associated with adverse outcome.

Retrospective cohort study with prospective long-term follow-up conducted at a tertiary spinal referral centre.

Seventy-two patients with degenerative CES confirmed by multidisciplinary team consensus and clinical-radiological correlation.

Long-term patient-reported outcomes across seven domains: bladder, bowel, sexual function, mobility, pain, mental health, and activities of daily living. An unweighted multidomain burden score was constructed from 0 to 7, with extensive burden defined as four or more affected domains. Global outcomes included perceived symptomatic improvement, satisfaction, and willingness to undergo surgery again.

Patients with confirmed degenerative CES were identified from a tertiary spinal centre cohort and contacted for structured long-term follow-up. Outcomes were assessed using a domain-based patient-reported questionnaire. Residual dysfunction was recorded across seven functional domains and combined into a multidomain burden score. Comparative analyses were performed between clinically relevant subgroups, including CES-retention versus CES-incomplete status and presence versus absence of persistent bladder dysfunction. Exploratory regression analyses were performed to identify predictors of high multidomain burden and persistent bladder dysfunction.

Seventy-two patients were included, with a mean age of 49.3 ± 14.8 years and median follow-up of 5.2 years (IQR 2.9-7.2). Residual dysfunction was common: bladder dysfunction persisted in 51.4%, bowel dysfunction in 37.5%, sexual dysfunction in 54.2%, and mobility limitation in 58.3%. Overall, 90.3% of patients had impairment in at least one domain, 72.2% in three or more domains, and 61.1% demonstrated extensive multidomain burden. Despite this, 79.2% reported symptomatic improvement, 86.1% would choose surgery again, and 70.8% reported high satisfaction, demonstrating discordance between persistent deficits and perceived benefit. Persistent bladder dysfunction was associated with more extensive multidomain burden compared with no bladder dysfunction (5.65 ± 1.32 vs 2.37 ± 1.75, p<0.001) and greater functional limitation. CES-retention versus CES-incomplete status did not significantly differentiate long-term outcomes. Increasing age was associated with both multidomain burden and persistent bladder dysfunction.

Long-term outcomes after CES are characterised by persistent multidomain disability rather than isolated deficits. Most patients experience residual impairment across multiple functional domains, yet many still report symptomatic improvement, satisfaction, and willingness to undergo surgery again, highlighting a satisfaction-deficit paradox. Persistent bladder dysfunction appears to be a key driver of long-term outcome. These findings support a shift from single-domain endpoints toward multidimensional outcome assessment, comprehensive long-term follow-up, and more realistic patient counselling.