Cauda Equina Syndrome: Is it Curable? (+ Recovery Time)

Are you wondering what cauda equina syndrome is and its consequences? Are you seeking clear answers based on reliable scientific information, along with testimonials from individuals who have gone through this experience?

As a physical therapist, I delve into this article covering its causes, symptoms, available treatments, and the prognosis in terms of recovery. I draw upon my experience with people who have had cauda equina syndrome and research from medical studies published worldwide (references at the end of the article).

Happy reading! If you have comments, experiences to share, or questions, feel free to join the discussion in the comments section 🙂.

If you would like more information about this rehabilitation period, I have dedicated an eBook to this topic 🙂!

Last update: November 2023
Disclaimer: Amazon Affiliate link. Complete disclosure in legal notices.
Written by Nelly Darbois, physical therapist and scientific writer

Summary

What is cauda equina syndrome concretely?

In the back, we all have a spinal cord. It is inside the vertebral column, extending from the brain to the coccyx, at the base of the spine.

It consists of nervous tissue and nerve fibers, or nerves. These nerves originate from the spinal cord and transmit and receive information from various parts of the body, including the limbs, trunk, face, and more.

A portion of the spinal cord is called the cauda equina. It is the bottom part of the spinal cord and is named so because its shape resembles that of a horse’s tail.

We can clearly see the shape of the horse's tail at the bottom of this spine MRI. The MRI also shows cauda equina syndrome — We can clearly see the shape of the horse’s tail at the bottom of this spine MRI. The MRI also shows cauda equina syndrome

The nerves that originate from the cauda equina are responsible for transmitting nerve signals between the spinal cord and various parts of the lower body, including the legs, pelvic muscles, genitals, buttocks, and some muscles of the intestines and bladder.

Definition of cauda equina syndrome

Cauda equina syndrome is the name of a problem that affects this part of the body, the cauda equina.

More precisely, we talk about cauda equina syndrome when the nerves that compose it are compressed or damaged, causing symptoms.

One or more of these nerves may be affected:

Spinal nerves, which originate at the lumbar level, are called L2, L3, L4, L5;
Spinal nerves that originate from the sacrum, called S1, S2, S3, S4, S5;
The coccygeal nerve, at the coccyx level.

This is why you may see this sequence of letters and numbers on your examination reports.

Since the cauda equina is affected, we will have problems in the lower body and the different parts controlled by the cauda equina.

This happens in different situations that I will detail later in the section on the causes of cauda equina syndrome.

Symptoms of cauda equina syndrome

Here are the clinical signs that may suggest cauda equina syndrome. You may have only a few of them:

+++ Sudden dysfunction of the bladder, intestines, and sexual function: you have difficulty holding in urine, you wet yourself, you no longer have an erection, etc. You may also experience difficulty urinating or be unable to completely empty your bladder (= urinary retention). This is the most important factor to consider for the diagnosis (Hawa 2023). We also speak of incomplete lumbar canal syndrome if there is no urinary problem (Srikandarajah 2020).
Sharp (= recent, for a few days or weeks) or chronic (for several months) pain in the lower back, at the lumbar level;
Numbness or loss of sensation in the groin, buttocks, or genital area;
Sudden muscle weakness in the legs, difficulty walking or moving the legs, difficulty coordinating movements;
Sciatica-like pain radiating down the leg, severe lower back pain, pain radiating into the buttocks, legs, or feet, generally on one side.

Recent publications call into question the relevance of all these signs. Because only 32% of symptoms/signs are true “red flags,” indicating potentially avoidable damage (Todd 2017).

The clinical signals of cauda equina syndrome are very varied. They have no predictive value on the outcome. This means that even if you have many intense symptoms, it doesn’t necessarily mean you will recover less well (Hawa 2023).

⚠️ In 43% of cases, when faced with this type of clinical sign, a diagnosis of lumbar canal stenosis is made when, in reality, the person does not have it (Hawa 2023).

Who to consult for the diagnosis of cauda equina syndrome?

It is very difficult to self-diagnose cauda equina syndrome because there are other conditions that resemble it, such as a “simple” sciatica.

That’s why, faced with these signs that you find abnormal, you can consult your general practitioner. If the symptoms suggest cauda equina, your doctor:

will prescribe an MRI or a CT scan;
or will refer you to a neurosurgeon or another specialist for further management.

Photo of MRI results showing cauda equina syndrome caused by a herniated disc

As a physical therapist, we are also trained to identify what we call ‘red flags.’ Signs in our patients that suggest cauda equina syndrome.

That’s why your physiotherapist may also sometimes refer you for a diagnosis and additional imaging.

These additional examinations will allow:

to confirm that it is indeed cauda equina syndrome;
to identify its cause.

Health professionals are trained to perform what is called a differential diagnosis: to detect, through examination and, if necessary, imaging, whether it is cauda equina syndrome, coccyx fracture, or a ‘simple’ sciatica or lower back pain, among others.

An infographic was created to try to facilitate the medical journey of someone suspected of having narrow lumbar canal syndrome
This infographic was created to try to facilitate the medical journey of someone suspected of having narrow lumbar canal syndrome. Source: Paling 2022 — An infographic was created to try to facilitate the medical journey of someone suspected of having narrow lumbar canal syndrome This infographic was created to try to facilitate the medical journey of someone suspected of having narrow lumbar canal syndrome. Source: Paling 2022

What causes cauda equina syndrome?

The most common cause of cauda equina syndrome is a lumbar herniated disc, accounting for 45% of all cases of this condition.

Having a lumbar herniated disc doesn’t necessarily mean you have cauda equina syndrome! In fact, it’s more of an exception when that’s the case. Many people have herniated discs but never experience any symptoms (not even back pain).

Other causes that can trigger cauda equina syndrome include:

Spinal stenosis = the canal through which the spinal cord passes narrows, often due to osteoarthritis, a congenital issue, or aging,
Cysts,
Fractures (e.g., vertebral compression),
Tumors,
Infection,
Spinal manipulation (in osteopathy, chiropractic, or manual therapy),
Spinal anesthesia,
Or any other injury capable of compressing the cauda equina. For instance, postoperative cauda equina syndrome may occur after surgery, often back surgery such as lumbar herniated disc surgery, spinal stenosis surgery, or spinal tumor surgery.

The most common cause of cauda equina syndrome is a herniated disc, but there are many other possible causes.

Source: Hawa 2023

photo d'un résultats d'irm montrant un syndrome de la queue de cheval avec une sténose sacrée et une masse qui comprime les nerfs — MRI revealing a significant mass of soft tissues in the sacral region causing significant canal stenosis and compression of the sacral nerve roots leading to cauda equina syndrome.

What are the treatments for cauda equina syndrome?

Surgery is the most common treatment for cauda equina syndrome. Today, I’ll provide an overview of what is known about the effectiveness and risks of various proposed treatments.

Depending on the cause of the syndrome, other treatments may also apply.

Surgery for cauda equina syndrome?

The syndrome has been the subject of studies on its treatments for several decades. However, it is still relatively rare (2 people per 100,000 have it).

Syntheses of recent studies (Srikandarajah 2020 and Hawa 2023) have observed that:

The treatment of cauda equina syndrome most often involves surgical decompression, although the effectiveness of surgical treatment has been questioned.
The urgency of surgical decompression is controversial. While it is generally recommended to treat cauda equina syndrome with urgent surgery, some have argued that delaying surgery could be beneficial.
There is very little data on the long-term outcomes, with or without treatment, for cauda equina syndrome.

What to do while waiting for better-quality data? You can simply discuss with your surgeon, physician, or physical therapist the various possible scenarios for you and the pros and cons of each, keeping in mind the uncertainty.

Physical therapy for cauda equina syndrome?

Physical therapy sessions are often prescribed in the case of cauda equina syndrome, whether operated or not. Your physiotherapist will conduct an assessment, and based on this assessment, goals can be defined:

Manage chronic or acute pain.
Preserve or regain joint flexibility and muscle strength.
Compensate for any deficits.
Regain better sphincter control.

There are no studies comparing the outcomes of people with or without physiotherapy in the diagnosis of cauda equina syndrome. However, there are some case studies.

It’s up to you to assess the benefits and constraints you derive from your physiotherapy sessions to decide whether to continue them or not.

If you would like more information about this rehabilitation period, I have dedicated an eBook to this topic 🙂!

Orthotics, braces, heel lifts, proper footwear for cauda equina syndrome? ?

A team of Indian rehabilitation specialists suggests wearing 1 cm heel lifts to improve the walking of people with cauda equina syndrome (Kurien 2020).

Their explanation is that when the sacral nerve roots are affected (those starting with S-: S1, S2, etc.), walking is often hindered due to:

Excessive ankle flexion.
Knee flexion during the support phase.
Reduced ankle push at the beginning of the pre-swing phase.

To compensate for this, ankle-foot orthoses with an anterior stop set at 5° plantar flexion can be used, or heel lifts, which are easier to put in place and less aesthetically bothersome.

If walking is very uncomfortable for you, this is an option you can try for a few days, as it is quite easy to implement. You can make a makeshift heel lift with what you have at home, buy one in a shoe or sports store, or on Amazon or another website.

Of course, this is not a treatment for the syndrome per se, but simply a compensation. Your physiotherapist or occupational therapist can probably suggest other tricks of this kind tailored to your situation.

Exercise for cauda equina syndrome?

Physical exercise has a positive impact on many parameters of our physical and mental health.

In the case of cauda equina syndrome, it can contribute to strengthening muscles and maintaining or recovering joint mobility. It can also have an indirect effect on pain because when we are active (compared to sitting in front of a TV series, for example), we secrete hormones that promote well-being.

However, what we know about the mechanisms behind cauda equina syndrome makes it unlikely that exercise can directly influence or cure nerve compression.

There is also no study evaluating the recovery of people who regularly practice exercises or physical activity in the case of cauda equina syndrome, compared to those who do not.

What type of exercise is most likely to relieve back and leg pain?

Well… we don’t know. There are many studies that evaluate doing certain types of physical exercises compared to doing nothing, for example, stretching, water movements, etc. But few studies compare people who do one type of exercise to another.

In practice: do what brings you the most pleasure or well-being at the moment and is least burdensome for you!

Extract from a study attempting to assess which type of exercise is more effective against back pain (including cauda equina syndrome). The figures show the number of studies for each type of physical exercise; the larger the circle, the more this form of physical activity has been evaluated. Image: Owen 2020

Osteopathy for cauda equina syndrome?

Cauda equina syndrome is primarily caused by compression or severe injury to the nerve roots of the spinal cord in the lumbar region.

The complex biomechanical mechanisms and structural damage involved make it unlikely that osteopathy (or another manual therapy) can directly resolve this problem.

There is no specific study on osteopathy in the case of cauda equina syndrome.

What recovery is possible from cauda equina syndrome?

I completely understand that you may want to know precisely how and when you will recover.

However, be aware that the symptoms you have when the syndrome appears do not allow us to say whether or not you will recover and at what speed. A prognosis cannot be made based on these symptoms (Hawa 2023).

The only known prognostic factor is that young people (in their twenties) are more at risk of having sequelae in terms of sexuality. This leads a research team to emphasize the following:

Addressing the issue cannot be left to the patient and is the solemn responsibility of the doctor: too often, the patient is unaware of the link between cauda equina syndrome and sexual dysfunction and is too embarrassed to ask the question.
Korse 2017

Can cauda equina syndrome be cured?

A study evaluated the recovery of people who had decompression surgery following cauda equina syndrome 6 to 23 years after the operation. Of the 46 people surveyed:

38% had problems with urination,
43% had problems with defecation (bowel movements),
and 54% had problems with sexuality.

These high figures are, of course, related to people of the same age who might also have concerns in these areas. Nevertheless, these figures suggest that a complete recovery from sphincter and sexual disorders is still possible after cauda equina syndrome.

These people had also been evaluated 56 days after the operation. 56 days after the operation, a larger proportion of them reported problems of this type, as shown in the table below:

This means that one can continue to recover from urinary disorders several months or even years after the onset of symptoms and the operation for cauda equina syndrome.

Source: Korse 2017

Do we necessarily retain sequelae after a cauda equina syndrome?

No, we do not necessarily retain sequelae after cauda equina syndrome. Even though sequelae still affect up to 1 person out of 2.

In the recently cited study, we see that some people no longer have any discomfort in the medium or long term (at least in terms of urinary, fecal, and sexual disorders).

Pain is much more difficult to assess and monitor because many people experience back or leg pain without having cauda equina syndrome.

And we do not have data on the evolution and sequelae in terms of motor function.

Where to find testimonials on the evolution of cauda equina syndrome?

I know that many people are looking for testimonials on the evolution of this syndrome. Because testimonials are often more telling than figures and statistics drawn from studies.

The limitation of testimonials is that it is really difficult to draw something for one’s own case. And they can sometimes be partial: our memory can play tricks on us and not remember everything.

Nevertheless, here are some ways to find such testimonials:

Go to forums such as WebMD, HealingWell, PatientsLikeMe. Type the keyword ‘cauda equina syndrome’ in their search bar, or even simply in your general search engine with the forum’s name.
Join a Facebook group for patients. Type ‘Cauda Equina Syndrome’ in Facebook’s search bar.
Use a hashtag #caudaequinasyndrome on Instagram or TikTok. You will come across accounts that address this topic, often from patients.

More questions or remarks? See you in the comments!

If you feel the need to learn more about the recovery period, I wrote this guide in eBook format:

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Cauda Equina Syndrome: Is it Curable? (+ Recovery Time)