Vice Chairman & Head - Ortho Spine, MIS & Robotic Spine Surgery, BLK-Max Super Speciality Hospital, New Delhi
Part 3 of 10 in Indications for Spine Surgery & Advances for Safer Outcomes
Cauda Equina Syndrome and the Spine Emergencies That Cannot Wait
August 27, 2026
Most spine referrals can wait days or weeks without lasting consequence. A small group cannot, because the nerve or cord damage involved is often permanent once it happens. Dr. Puneet Girdhar treats three specific presentations as same-day emergencies.
The cauda equina triad
Cauda equina syndrome presents as a triad: saddle anesthesia, weakness in both lower limbs, and difficulty controlling urine. The mechanism is tremendous pressure on the lumbar spinal nerves, usually from a large central disc herniation, and the syndrome is treated as a surgical emergency because the nerve roots involved have a narrow window before compression becomes permanent injury.
A cord under increasing pressure
The second emergency is a progressive neurological deficit, which can come from cervical or dorsal myelopathy or from an osteoporotic fracture that keeps retropulsing into the canal. What marks this group is the word progressive: the patient's walking ability and numbness are getting worse day by day, not staying stable, which is what turns a chronic condition into something that needs same-day attention.
Infection, malignancy, and fracture
Any suspected infection, malignancy, or vertebral fracture requires emergency referral on its own, independent of the patient's current neurological status. Girdhar's practice sees a steady volume of infective spondylodiscitis and tuberculous spine alongside these, and delay in any of the three risks structural collapse or neurological involvement that a same-day referral would have prevented.
Pain intensity is not the signal to watch
A patient can be in severe pain without meeting any of these three criteria, and a patient with relatively mild pain can still be a genuine emergency if the triad or a progressive deficit is present. The decision to refer same-day rests on this specific red-flag pattern, not on how much the patient is hurting.
This guide is based on a live Jivo Masterclass — Dr. Puneet Girdhar taught doctors across Africa on March 15, 2026.
FROM THE LIVE Q&A
Dr. Innocent Nzili (Kenya)
A 32-year-old male has a diffuse L4-L5 disc bulge compressing both traversing nerve roots, a left paracentral L5-S1 disc protrusion narrowing the left lateral recess, and canal stenosis measured at 9.5 millimeters. He is exhausted by medication and physiotherapy but afraid of surgery. What would you recommend?
Dr. Puneet Girdhar
If there is no significant back pain and no instability, we prefer decompression alone, either bipartal endoscopy through two ports of 4 to 5 millimeters to 1 centimeter, or an MIS tubular approach through a single 2.5 centimeter incision, adding a discectomy at the same sitting if the disc is large. If there is significant back pain and the dynamic X-ray shows instability, lysis, or discal collapse with foraminal stenosis, he will need a TLIF with a cage and screws to restore disc height and decompress both foramina. If he is already exhausted by medication and physiotherapy and still suffering, he almost certainly needs surgery; that is exactly why he is still hanging around doctors trying to find another way.
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Frequently Asked Questions
What were you and your colleagues hoping to take away from this session?▼
Spinal surgery takes most of the surgical case volume in neurosurgery at my center in Nigeria. We were expecting to see the procedures Dr. Girdhar uses and how they aid recovery, not only the traditional open decompression we already practice, but also how he performs minimally invasive spine surgery, since it is still an emerging area for us.
How is minimally invasive surgery actually done, since we currently only perform open surgery at our center?▼
I would request that we spend time together if you are planning to come to India, please come to Delhi to our center. I tried my best, but that is all you can cover in an hour when it represents twenty years of work with a lot of technology behind it. You need to observe more, and that would let you move on to minimally invasive work. It is not difficult, but everything new you start in your practice is a steep curve at first, though very achievable, looking at how many MIS centers exist in the world today.
How should we set up communication so patients from Zambia can reach you with their reports?▼
My availability is never really an issue. I usually reply the same day, before going to bed, to most of the queries I get, and I hear from 30 to 40 people a day from all over the place. We look forward to working together and helping your patients from Zambia, at the very least by providing an opinion.
Closing thought on the session▼
Thank you for a very impressive, interesting presentation.
Closing thought on the session▼
Today it seems we were not leaving any stone unturned, so detailed.
What are the three symptoms of the cauda equina triad?▼
Saddle anesthesia, weakness in both lower limbs, and difficulty controlling urine.
What usually causes cauda equina syndrome?▼
Tremendous pressure on the lumbar spinal nerves, usually from a large central disc herniation.
What distinguishes a chronic neurological condition from one needing same-day referral?▼
The word progressive. The patient's walking ability and numbness must be getting worse day by day, not staying stable, to qualify as an emergency.
Does how severe a patient's pain is indicate whether their case is an emergency?▼
No. A patient can be in severe pain without meeting any of the emergency criteria, while a patient with relatively mild pain can still be a genuine emergency if the triad or a progressive deficit is present.
What spinal infections require the same emergency referral as cauda equina syndrome?▼
Infective spondylodiscitis and tuberculous spine, alongside any suspected malignancy or vertebral fracture, referred the same day regardless of pain level.
In This Series: Indications for Spine Surgery & Advances for Safer Outcomes
- 1.Indications for Spine Surgery
- 2.The Three-Tier Referral System: When Back and Neck Pain Needs a Spine Surgeon
- 3.Cauda Equina Syndrome and the Spine Emergencies That Cannot Wait
- 4.A Case Worked Through by Phone: Decompression or Fusion for a Kenyan Patient
- 5.Minimally Invasive Reduction for Spondylolisthesis: Two Cases From the Same Month
- 6.A Fusion Mass at Twenty-Four: Revising a Childhood Scoliosis Correction That Stopped Short
- 7.Loose Screws and a Cord That Was Swelling Somewhere Else Entirely
- 8.When Cement Alone Is Not Enough for a Fractured Vertebra
- 9.Training the Next Generation: Inside a Two-Year Spine Fellowship and Its Observership Track
- 10.Cross-Border Spine Care: Inside the Jivo Connect Clinic Model