Cauda Equina Syndrome: Poor Recovery Prognosis Despite Early Treatment

Alexia Planty-Bonjour, MD; Gaelle Kerdiles, MD; Patrick François, MD, PhD; Christophe Destrieux, MD, PhD; Stephane Velut, MD, PhD; Ilyess Zemmoura, MD, PhD; Ann-Rose Cook, MD; Louis-Marie Terrier, MD; Aymeric Amelot, MD, PhD


Spine. 2022;47(2):105-113. 

In This Article

Abstract and Introduction


Study Design: A prospective patient's database operated on a cauda equina syndrome (CES).

Objective: The aim of our study was to identify prognosis factors for favorable functional recovery after CES.

Summary of Background Data: CES is a neurologic impairment of variable symptoms associating urinary, bowel, and sexual dysfunctions with or without motor or sensitive deficits caused by nerve root compression of the cauda equina. The definition of CES remains debated, as well as the prognosis factors for favorable functional recovery and the benefit of early surgery.

Methods: One hundred forty patients were included between January 2010 and 2019. Univariate and multivariate cox proportional hazard regression models were conducted.

Results: The patients were young with a median age of 46.8 years (range 18–86 yrs). At presentation, 60% were affected by a motor deficit, 42.8% a sensitive deficit, 70% urinary dysfunctions, and 44% bowel dysfunctions. The mean follow-up was 15.5 months. Bilateral motor deficit (P = 0.017) and an initial deficit severity of 0 to 2 (P = 0.001) represented prognosis factors of poor motor recovery. Initial anal incontinence (P = 0.007) was associated with poor bowel recovery. Only 32.8% of the patients went back to work. Initial motor deficit (P = 0.015), motor sequelae (P = 0.001), sphincter dysfunctions sequelae (P = 0.02), and long LOS (P = 0.02) were poor return-to-work prognosis factors. Time to surgery within an early timing < 24 or 48 hours or later did not represent a prognosis factor of recovery in CES. Incomplete versus complete CES did not show better recovery.

Conclusion: CES remains a profound disabling syndrome with poor functional prognosis: in the long run, few patients go back to work. The main prognosis factors established in our series regarded the initial severity of deficits whether motor or sphincteral. Early or later surgical cauda equina decompression did not show to represent a prognosis factor for functional recovery.

Level of Evidence: 4


Cauda equina syndrome (CES) is a neurologic impairment caused by the compression of nerve roots of the cauda equina.[1] CES is a rare compression, representing approximately one or two per 100,000.[2,3] Herniated lumbar disc is the most common etiology[4] and occurs in 1% to 10% of cases.[5–7]

An exact definition of the cauda equina syndrome remains unclear. In 1934, Mixter and Barr[8] were the first to describe symptoms of numbness, tingling, anesthesia, loss of power of locomotion, and bladder/rectal sphincter disorders, in a context of rupture of the intervertebral disc.

Later, in 1959, Shephard[9] defined cauda equina syndrome as a weakness of muscles below the knees, impairment of skin sensation in the saddle area, micturition difficulties, and radiating symptoms.

In 2002, Gleave and Macfarlane[10] defined two subtypes of CES: 1) incomplete-CES (CES-I) for patients with urinary difficulties of neurogenic origin, including altered urinary sensation, loss of desire to void, poor urinary stream, and the need to push to micturate; and 2) complete-CES (CES-C) for patients with painless urinary retention and overflow incontinence, where the bladder is no longer under executive control.[10]

In 2009, Fraser et al.[2] through a meta-analysis composed by 105 articles, defined CES as a state with at least one of the following symptoms: bladder and/or bowel dysfunction, reduced saddle area sensation, or sexual dysfunction with a potential neurologic deficit in the lower limbs.

Several studies defined CES with poor prognosis. Indeed, at long-term follow-up (FU) of CES patients, 36% presented micturition dysfunction sequelae, 40% defecation dysfunction, 50% sexual dysfunction, and 50% a motor deficit. The disabling nature of these sequelae causes significant medical and social morbidity as well as high socioeconomic costs.[6,11,12]

Furthermore, many studies have focused on prognosis factors especially concerning the time duration of symptoms before surgery but few of them focused on other prognostic factors such as complete or incomplete-CES, multilevel involvement, bilateral versus unilateral sciatic pain, or the presence of saddle anesthesia.[7,13–15] To date, the literature has clearly not identified any prognosis factors. Surgical management time is remarkably debated in the aim to obtain better outcomes and limit sequelae.

In our study, through a large series of operated CES patients, we aimed to identify prognosis factors for favorable functional recovery and to determine the real favorable impact of early surgery.