Diagnostic and Surgical Challenges of Cauda Equina Syndrome in Elderly Patients with Diabetes Mellitus: A Systematic Review and Meta-Analysis of Clinical, Radiological, and Surgical Outcomes.

BACKGROUND: Cauda equina syndrome (CES) is a rare but severe neurological emergency requiring urgent surgical decompression. In elderly patients with diabetes mellitus, overlapping neuropathic features may obscure classical CES presentation, leading to delayed diagnosis and worse outcomes. OBJECTIVES: To evaluate diagnostic challenges, surgical management, perioperative complications, and recovery outcomes in elderly diabetic patients with CES. METHODS: A systematic search of PubMed/MEDLINE, Embase, Scopus, Web of Science, and Cochrane CENTRAL was conducted 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 conducted, and heterogeneity was assessed using the I² statistic. RESULTS: Twenty-eight studies, published between 2016 and 2025 across 14 countries, comprised 1,427 elderly patients with diabetes mellitus and confirmed CES were analyzed. The pooled mean diagnostic delay was 4.8 days (95% CI: 3.9-5.7). Saddle anaesthesia was absent at presentation in 38.7% of patients. Surgical decompression within 48 hours significantly improved bladder recovery (OR: 2.74; 95% CI: 1.89-3.97; I²=38%). Each 1% increase in preoperative HbA1c was associated with a 4.3% reduction in neurological recovery (p=0.003). The pooled complication rate was 34.7% (95% CI: 29.1-40.3%), and 30-day mortality was 2.2%. CONCLUSIONS: Elderly diabetic patients with CES experience delayed diagnosis and increased perioperative risk. Early surgical decompression within 48 hours and optimal glycaemic control are key determinants of improved outcomes. Tailored diagnostic pathways for this population are warranted.