A 35-year-old male presents with acute-onset severe low back pain radiating to the left L5 dermatome (dorsum of foot, big toe) with foot drop. MRI shows a large left paracentral disc herniation at L4-L5 level. He also has bilateral leg weakness, saddle anesthesia, and acute urinary retention. The MOST urgent management priority is:
- A IV methylprednisolone pulse therapy
- B Emergency surgical decompression (microdiscectomy/laminectomy) within 24-48 hours ✓
- C Emergency MRI of the entire spine to rule out other levels
- D Conservative management with NSAIDs and bladder catheterization, with surgery if no recovery in 6 weeks
Explanation
Cauda equina syndrome (CES) is defined by bilateral leg weakness, saddle anesthesia, and sphincter dysfunction (acute urinary retention is the 'complete' form — CES-R). It is a surgical emergency. Emergency decompressive surgery within 24-48 hours (ideally <48 hours of onset) is strongly recommended to maximize neurological recovery, particularly bowel/bladder function. Delay beyond 48 hours significantly worsens prognosis for continence and motor recovery. CES-R (with retention) has worse prognosis than CES-I (incomplete). Steroids are used for acute spinal cord injuries but evidence in CES is limited.
Reference: Maheshwari Essential Orthopaedics, 6th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.