Cauda equina syndrome (CES) is a rare but severe neurological emergency that requires urgent surgical decompression to prevent permanent neurological deficits. In elderly patients who have diabetes mellitus, overlapping neuropathic features can mask classical CES symptoms and complicate clinical recognition. The interaction between chronic diabetic neuropathy and the acute compressive pathology of CES raises distinct diagnostic and perioperative management challenges in this population.
This systematic review and meta-analysis aimed to evaluate diagnostic challenges, surgical management, perioperative complications, and recovery outcomes specifically in elderly patients with diabetes mellitus diagnosed with CES. The review focused on quantifying diagnostic delay, symptom presentation differences, the effect of surgical timing on recovery endpoints, the association of glycaemic control with neurological recovery, and perioperative risk estimates.
A systematic search covered PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane CENTRAL for studies published between January 2015 and April 2026. Two independent reviewers performed study selection, data extraction, and risk-of-bias assessment. Random-effects meta-analyses were used to pool estimates, and heterogeneity was assessed with the I² statistic. The report presents pooled means, odds ratios, confidence intervals, and p values where available from the included studies.
Twenty-eight studies from 14 countries published between 2016 and 2025 were included, yielding a pooled sample of 1,427 elderly patients with diabetes mellitus and confirmed CES. The included studies provided clinical, radiological, and surgical outcome data that were synthesized for pooled estimates reported below.
Across the pooled cohort, the mean diagnostic delay from symptom onset to diagnosis was 4.8 days (95% CI: 3.9–5.7). A substantial proportion of patients did not exhibit classical CES sensory findings: saddle anesthesia was absent at presentation in 38.7% of patients. The absence of this hallmark symptom likely contributes to delayed recognition and referral for neurosurgical assessment in elderly patients with diabetes, where baseline sensory impairment may already be present.
Timing of decompressive surgery emerged as a key determinant of functional recovery. The pooled analysis demonstrated that surgical decompression performed within 48 hours of presentation significantly improved bladder recovery compared with later surgery (OR: 2.74; 95% CI: 1.89–3.97; I²=38%). This finding supports expedited surgical management for CES in elderly diabetic patients when feasible. The moderate heterogeneity (I²=38%) suggests some variability across studies but an overall consistent benefit in early decompression for urinary outcomes.
Preoperative glycaemic control, as measured by HbA1c, was associated with neurological recovery. The pooled analysis reported that each 1% increase in preoperative HbA1c correlated with a 4.3% reduction in neurological recovery (p=0.003). This relationship indicates that poorer chronic glycaemic control is linked with worse post-surgical neurological outcomes in this cohort.
Perioperative morbidity was substantial in the pooled sample. The pooled complication rate across studies was 34.7% (95% CI: 29.1–40.3%). Short-term mortality was low but present: the pooled 30-day mortality was 2.2%. These pooled estimates emphasize elevated perioperative risk among elderly diabetic patients undergoing surgery for CES and underscore the need for careful perioperative assessment and optimization.
In elderly patients with diabetes mellitus, CES is frequently recognized late and presents atypically—saddle anesthesia may be absent in a sizeable minority. Early surgical decompression within 48 hours is associated with better bladder recovery, and better preoperative glycaemic control (lower HbA1c) is associated with improved neurological recovery. The overall perioperative complication rate is high (approximately one-third), with a 30-day mortality of 2.2% in pooled data. Clinicians should maintain a high index of suspicion for CES in elderly diabetic patients with acute low back pain, focal neurological signs, or new bladder/bowel dysfunction, and consider expedited imaging and surgical referral.
The review pooled observational studies across multiple countries and settings, which introduces clinical and methodological heterogeneity reflected in reported I² values. Specifics of individual study designs, case selection, imaging criteria, surgical techniques, and perioperative care protocols were not detailed in the abstract. Where the source did not report granular data or subgroup analyses, those details are not provided here. Based on the reported findings, practical recommendations include rapid diagnostic pathways tailored to elderly diabetic patients, prioritization of decompression within 48 hours when clinically appropriate, and attention to optimization of glycaemic control preoperatively. Further research should clarify optimal perioperative glucose management strategies and refine diagnostic algorithms for this high-risk population.