Awareness and Diagnostic Accuracy of Cauda Equina Syndrome: A Multicenter Study Among Emergency and Primary Care Physicians.

Introduction: Cauda Equina Syndrome (CES) is a neurosurgical emergency characterized by motor and sensory deficits in the lower limbs, pelvic floor and sphincters. Hallmark symptoms include low back pain, saddle anesthesia, bilateral sciatica and bladder dysfunction. Delayed diagnosis and intervention can lead to irreversible neurological damage. This study assessed the diagnostic and management proficiency of emergency medicine and primary healthcare physicians, aiming to identify knowledge and training gaps contributing to CES-related delays. Methods: A multicenter cross-sectional study was conducted among 274 physicians in emergency and primary care settings across Saudi Arabia. Participants were interviewed using structured, scenario-based clinical vignettes to evaluate decision-making accuracy in realistic CES presentations. The sample included residents, specialists and consultants from family medicine, general practice and emergency medicine. Results: Scenario-level accuracy ranged from 42.0% for recognizing the need for urgent decompression within 48 hours to 63.1% for selecting MRI as the imaging of choice in classic CES. Diagnosis of CES in bilateral sciatica with urinary retention was correct in 60.6% of cases. Physicians with ≤10 years of experience demonstrated significantly higher overall diagnostic accuracy and urgency recognition (p≤0.001). Residents adhered more closely to recommended management protocols, while specialists exhibited greater diagnostic precision. Conclusion: This study revealed substantial gaps in CES knowledge and diagnostic accuracy, particularly among senior physicians. Targeted education and standardized protocols are needed to improve recognition of red flags and ensure timely intervention. Reinforcing awareness of CES and the critical 48-hour surgical window may help prevent irreversible neurological harm.