The patient has signs and symptoms consistent with cauda equina syndrome, and an emergent surgical evaluation should be obtained. Cauda equina syndrome is an uncommon but potentially catastrophic condition that is caused by compression and ischemia of some or all of the 18 descending nerve roots that make up the cauda equina, with resulting neurologic impairment. Causes may be benign (such as degenerative changes, disk herniation, spondylosis, and other structural abnormalities of the spine; infection; or bleeding) or malignant (with multiple myeloma, lymphoma, and prostate cancers being the most commonly associated cancers). Classic clinical findings include acute low back pain, radicular pain, paresthesias or anesthesia in the perineal and upper thigh regions (termed “saddle anesthesia” due to its distribution in an area where a saddle would contact the body when riding a horse), urinary retention, fecal incontinence, lower extremity weakness, and decreased or absent distal reflexes. However, all of these features are uncommonly present early in the syndrome. For example, pain is the most common early symptom and may precede other neurologic findings; bowel and bladder dysfunction are usually late manifestations and do not occur in all patients. Early detection and surgical treatment offer the best chance of avoiding permanent neurologic damage, requiring careful evaluation of patients who might have this condition. Although this patient has incomplete clinical findings, rapid imaging and surgical evaluation are indicated.

Treatment with either epidural or high-dose glucocorticoids would be of unclear benefit in this patient because there is no definite evidence of an inflammatory disorder, and there is also no evidence suggesting that an acute compressive lesion would respond to glucocorticoids.

Examination of the cerebrospinal fluid would not be expected to be helpful in most patients with cauda equina syndrome and is not necessary to establish the diagnosis.