Which questions should you ask every patient with back pain to screen for cauda equina?
A recognise, screen and refer guide to cauda equina syndrome for UK physiotherapists, with clear, direct questions and safety-netting.
Subjective triage
- Ask directly about saddle or perineal numbness, including when wiping after the toilet.
- Ask about new difficulty starting or controlling urination, or loss of the sensation of a full bladder.
- Ask about bowel control and any change in sexual function.
- Note bilateral leg pain, numbness or weakness, or symptoms that are changing quickly.
- Use plain language and check understanding; patients may not volunteer these symptoms.
Differential dilemma: vs unilateral lumbar radiculopathy
| Feature | Cauda equina syndrome | Unilateral lumbar radiculopathy |
|---|---|---|
| Leg symptoms | Often bilateral or alternating | Usually one leg |
| Saddle sensation | Altered or reduced | Normal |
| Bladder/bowel | New change in function or sensation | Normal |
| Urgency | Time-critical emergency | Routine care with safety-netting |
Red flags: recognise, screen, refer
Recognise
- Saddle anaesthesia
- New urinary retention, hesitancy or incontinence
- Faecal incontinence or altered bowel sensation
- Sexual dysfunction
- Bilateral radicular symptoms or progressive weakness
Screen
Ask every patient with back or leg pain, document both positive and negative answers, and give written and verbal safety-netting advice.
Refer
Any suspicion of cauda equina syndrome needs same-day emergency assessment, following local pathways. Do not delay for further physiotherapy testing.
The clinical reasoning chain
- 1
History
Back pain with new bilateral leg symptoms and difficulty passing urine.
- 2
Pattern
Combination of bilateral neurology and bladder change raises concern for cauda equina compression.
- 3
Objective finding
Findings support but never rule out the concern; a normal examination does not exclude it.
- 4
Diagnostic decision
Suspected cauda equina syndrome: same-day emergency referral, documented clearly.
Quick reference FAQ
Should physiotherapists perform a rectal examination?
No. Physiotherapists screen through history and neurological examination, then refer urgently. Definitive assessment and imaging happen in emergency care.
What safety-netting should I give?
Explain the warning symptoms in plain language, give them in writing and tell the patient to attend A&E immediately if they occur.
Can cauda equina develop later in an episode?
Yes. Symptoms can evolve, so re-screen at follow-up appointments and whenever symptoms change.