GPAtlas🧭 When to suspect
These are two neurological emergencies that hide inside an everyday presentation – back pain. The overwhelming majority of back pain is benign and self-limiting, and the NICE low back pain and sciatica guideline deliberately does not cover progressive neurological deficit or cauda equina syndrome, precisely because these need a different, emergency response. The skill in primary care is to spot the small number of patients whose back pain is the first sign of cord or nerve-root compression, and to refer them before the deficit becomes permanent.
Spinal cord compression (SCC) is compression of the spinal cord, typically above L1/L2, producing upper motor neurone (UMN) signs. In adults the commonest serious cause is metastatic spinal cord compression (MSCC) – an oncological emergency. Cauda equina syndrome (CES) is compression of the lumbosacral nerve roots below L1/L2, producing lower motor neurone (LMN) signs; the commonest cause is a large central lumbar disc prolapse – a surgical emergency.
The key habit is to ask the bladder, bowel, sexual and saddle questions in every patient with significant back or bilateral leg pain, and to act on suspicion. No single symptom or sign is pathognomonic, and a normal examination never excludes either diagnosis.
| Feature | Spinal cord compression (often MSCC) | Cauda equina syndrome (CES) |
|---|---|---|
| Level | Spinal cord, usually above L1/L2 | Lumbosacral nerve roots, below L1/L2 |
| Commonest cause | Metastasis (breast, lung, prostate, renal, myeloma) | Large central disc prolapse |
| Motor pattern | UMN – spasticity, hyperreflexia, up-going (extensor) plantars | LMN – flaccidity, hyporeflexia/areflexia, down-going (flexor) plantars |
| Type of emergency | Oncological emergency | Surgical emergency |
| First action | Contact the MSCC coordinator immediately | Emergency referral to nearest unit with 24/7 MRI |
Raise suspicion of MSCC in anyone with a past or current cancer diagnosis and new, progressive or unremitting back pain; raise suspicion of CES in anyone with back or leg pain and new bladder, bowel, saddle or bilateral-leg symptoms.
Source: NICE NG234 · National Suspected CES Pathway (GIRFT) · NICE NG59
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