A 30-year-old man presents with acute sciatica after lifting a heavy object. MRI reveals a large L4–L5 central disc herniation causing cauda equina compression. Clinically, he has bilateral leg weakness, saddle anaesthesia, and urinary retention. The most important management decision is:
- A Urgent surgical decompression within 24–48 hours of onset of sphincter dysfunction ✓
- B Trial of 6 weeks conservative therapy with physiotherapy and NSAIDs
- C High-dose oral corticosteroids for 5 days
- D Traction and epidural steroid injection
Correct answer: A. Urgent surgical decompression within 24–48 hours of onset of sphincter dysfunction
Explanation
Cauda equina syndrome (CES) with sphincter dysfunction (urinary retention or incontinence) is a surgical emergency. Evidence supports decompressive surgery within 24–48 hours of symptom onset to maximise recovery of bladder, bowel, and sexual function. Delayed surgery beyond 48 hours significantly worsens sphincter recovery outcomes. CES without sphincter involvement (incomplete CES) is urgent but allows slightly more time for planning. The clinical triad of saddle anaesthesia, bilateral leg weakness, and urinary retention constitutes complete CES — operate immediately.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.