Cauda Equina Syndrome—A 2025 Narrative Review

Back pain is a common presentation in healthcare settings. The most serious cause is cauda equina syndrome (CES), a surgical emergency caused by acute compression of the lumbosacral nerve roots. In the UK, diagnosis requires a thorough clinical examination and emergency magnetic resonance imaging (MRI). Once confirmed on imaging, definitive treatment is urgent surgical decompression usually within 24 hours. Delays in diagnosis or treatment can lead to life-changing consequences including bowel and bladder incontinence, sexual dysfunction, lower limb paralysis and chronic pain. This narrative review provides a 2025 update to the 2023 review published in this journal. It covers the anatomy, epidemiology, aetiology, pathophysiology, classification, clinical presentation, examination, investigations, differentials, treatment, and management of CES. Major updates are based on the new UK 2025 Getting It Right First Time (GIRFT) interactive pathway. Important changes include: (1) the standardisation and timing of red flag symptoms, (2) the use of bladder scans as a rule-in rather than rule-out investigation, (3) aim for 24-hour MRI local diagnostic capabilities with standardized imaging sequences and proximal scanning in absence of cauda equina compression, (4) declassification of CES, (5) emphasis on all patients with established CES to receive urgent decompressive surgery as National Confidential Enquiry into Patient Outcome and Death (NCEPOD) level 1/2. This review uses the authors' experience of suspected CES pathway improvement to propose a pathway for the management of suspected CES in the emergency department at district general hospitals without 24-hour MRI capability based on the most recent national GIRFT guidelines.