Cauda equina syndrome: a structured approach for the higher orthopaedic examination

To provide a focused, examination-oriented review of cauda equina syndrome (CES), covering definition and classification, clinical assessment, bladder dysfunction, emergency imaging and referral, surgical timing, and postoperative rehabilitation.

MEDLINE/PubMed and relevant national guidance were reviewed and updated to 22 August 2026. Priority was given to UK guidance, systematic reviews and multicentre studies, including the current Getting It Right First Time (GIRFT) national suspected CES pathway, updated in March 2026.

CES is a clinical syndrome of sacral nerve-root dysfunction and should not be defined by an MRI appearance or by painless retention alone. The current UK pathway recommends emergency MRI at the presenting hospital as soon as possible and within four hours of the radiology request, without prior spinal-team approval. Post-void residual (PVR) measurement is an adjunct: a value of at least 200 mL increases suspicion, but a lower value does not exclude CES. Routine digital rectal examination solely to assess resting anal tone is not required. Imaging-confirmed compression requires immediate spinal referral. Incomplete CES should be decompressed as quickly as possible; CES with retention should be treated within 24h of MRI under the current pathway.

For both the examination and clinical practice, the priorities are early recognition of sacral symptoms, rapid MRI, avoidance of false reassurance from a single bedside test, urgent senior-led decompression when compression is confirmed, and structured bladder, bowel, sexual and psychological rehabilitation.