The classical presentation of Cauda Equina Syndrome (CES) is often dramatic but at times as often it might be slow onset but progressive. The Cauda equina is so called because of its resemblance to a horse’s tail.

By definition CES is painful and asymmetric (at least at onset). The clinical dictum being ‘If it is not painful it is not cauda Equina Syndrome.’ This is because the Cauda equina contains all the nerves roots exiting from the lumbar enlargement (except L1) and the conical conus medullaris, the terminal segment of the spinal cord.

The typical history in Slow onset CES is that of worsening low backache of 3- 4 months duration.  CES presents with the cardinal symptoms of severe low back pain with sciatica, weakness and numbness in the buttocks, inner thighs, backs of your legs, genitalia and perianal area. There is accompanying retention or incontinence of bladder and bowel. Sexual dysfunction may come on suddenly in Acute CES.

Magnetic Resonance Imaging of the Lumbar spine is the imaging modality performed with and without intravenous contrast (shown below).


Magnetic Resonance Imaging Lumbosacral spine may confirm a large tumor measuring (yellow arrowheads) occupying the entire extent of the spinal canal compressing the roots of Cauda equina. These patient need surgery for tumor removal.


Lumbar Laminectomy and exposure of tumor (Neurofibroma)

The neurological deficits recover gradually following surgery for tumor excision. The mean duration of recovery for patients with total and near total paraplegia is 12 months. The most common pattern of recovery is motor weakness followed by bowel-bladder symptoms followed by sensory recovery.