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What is Cauda Equina Syndrome?

A Medical Negligence
Solicitor Explains

Introduction:

Cauda equina syndrome (CES) is a rare condition but one with a


disproportionately high medico-legal profile. Claims usually attract
substantial damages which are a reflection of the damaging and
distressing nature of the condition.

What is Cauda Equina Syndrome?

CES is the term used to describe compression of the nerves at the end of
the spinal cord within the spinal canal.

The terminology, “cauda equina”, literally means tail of horse and refers to
the normal anatomy of the end of the spinal cord in the low back where it
divides into many bundles of nerve tracts resembling a horse’s tail.

Compression of the spinal cord at this level can lead to serious and
permanent neurological injury. Although there are a number of potential
causes, CES occurs most frequently following a large lower lumbar disc
herniation, prolapse or sequestration.

Diagnosis

CES is usually characterised by the following so called ‘red flag’


symptoms:

 Severe low back pain.


 Sciatica – often bilateral but sometimes absent – especially at
L5/S1 with an inferior sequestration.
 Saddle and gentry sensory deficit.
 Bladder, bowel and sexual dysfunction.

Low back pain and sciatica are of course common, but bilateral sciatica
should always ring alarm bells. Its occurrence with any ‘red flag’
symptoms must trigger immediate action, generally involving emergency
referral to an accident and emergency department with ready access to a
spinal surgery unit – preferably accompanied by an explanatory telephone
call to reduce delays. The diagnosis is confirmed by prompt MRI scanning.
The availability of a 24-hour radiologist and MRI facilities may be crucial to
the outcome.

Three types of CES have been identified:

 Rapid onset without a previous history of back problems.


 Acute bladder dysfunction with a history of low back pain and
sciatica.
 Chronic back ache and sciatica with gradually progressing CES.

Within these groups, CES may be complete or incomplete and its onset
may be either acute (within hours) or gradual (over weeks or months).

CES incomplete (CES-i) and CES with retention (CES-r)

Although the above description is clinically useful, in medico-legal terms


the important distinction is whether, at any given time, the CES is
complete or incomplete in relation to urinary function and perineal
sensation.

When the syndrome is incomplete (CES-i), the patient has urinary


difficulties of neurological origin, including altered urinary sensation, loss
of desire to avoid, poor stream and the need to strain. Saddle and genital
sensory deficit is often unilateral or partial.

The complete syndrome (CES-r) is characterised by painless urinary


retention and overflow incontinence. There is usually extensive or
complete saddle and genital sensory deficit.

The outcome for patients with CES-i at the time of surgery is generally
favourable. Unfortunately, those who have deteriorated to CES-r by the
time the compression is relieved have a poorer prognosis.

Summary

CES occupies a prominent position in the medico-legal field, partly perhaps


through lack of awareness and urgency in its management and partly
because of the devastating consequences of inadequate management
which may lead to bowel, bladder, sexual and lower limb dysfunction.

In around half of cases, the die is cast within the first 4-6 hours of a severe
central disc prolapse resulting in CES-r. This is a very small window of
opportunity in which to achieve referral to an appropriate hospital,
confirmation of diagnosis by MRI scan and surgical decompression. It can
be argued that minor delays are not significantly related to causation in
these cases.

The situation with regards to CES-i is, however, very different. The window
of opportunity can extend over a much longer period, days or weeks.
Prompt treatment offers a good prognosis. The important issues is to
avoid CES-r.

In other words, prompt diagnosis and investigation, followed by a full


explanation and consent procedure before timely and skilful surgery and
rehabilitation, are the essentials of best practice in the treatment of this
rare, but often a very damaging, condition. It is a tragedy, often
avoidable, if an incomplete syndrome becomes complete when under
medical supervision.

About Medical Negligence:

It can be upsetting and painful to have been involved in a medical


accident where avoidable harm has been caused as a result of treatment
or a failure to treat. We at Pardoes believe that those affected by medical
accidents deserve an honest, straightforward and appropriate explanation,
support and compensation at a fair and just level.

About the Author:

James Wickett, Clinical Negligence Lawyer with Pardoes Solicitors

James studied law at Plymouth and Oxford before embarking on a career


specialising in complex clinical negligence work in Bristol. Returning to his
roots in North Devon he now works principally from Pardoes Solicitor’s
Taunton office, heading up clinical negligence there.