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Cauda Equina Syndrome

Cauda Equina – which the Latin Scholars amongst you will know translates to   “horse’s tail” - describes the appearance of the nerve roots coming out at the bottom end of the spinal cord. Cauda Equina Syndrome (CES) relates to compression of nerves in the lumbar spine. These nerves if compressed affect the muscle power in the legs, control of bowel, bladder and sexual function.

Compression can occur from pro-lapsing of the vertebral disk space (when one of the discs becomes damaged and presses on the nerves), narrowing of the spinal column at that level, infections of the spinal canal, including abscesses, tumours, and other inflammatory causes such as sarcoidosis, Paget’s disease, and ankylosing spondylitis. Other causes include: trauma to the spine, spinal anaesthesia, and lumbar punctures (a test to tap spinal fluid).

Patients may present in a manner of different ways. There are no particular risk factors for developing the condition, other than lifting heavy objects. Patients, commonly men 40-50 years of age, may present either acutely or progressively with weakness of the legs, numbness in the area around the anus (so called “saddle distribution”), urinary retention of the bladder, loss of bowel control, and or loss of male sexual function.

Although the cause may relate to damage to the vertebra, not all patients will necessarily have acute or progressive backache. Some patients may also describe stabbing pains shooting down the leg. In patients with abrupt onset of symptoms, the diagnosis may be more obvious. However, in cases where symptom progression is gradual, the diagnosis may be delayed. In cases with the above symptoms, a prompt diagnosis and treatment is essential to avoid or minimize permanent neurological damage.

 Backache is a very common symptom, and only occasionally is associated with CES. The usual cause for a late diagnosis is where patients who may have initially presented with backache, were not warned that if they developed other symptoms, such as numbness, bladder, or bowel disturbances, should seek further attention. In addition, if the original backache is not resolving, Cauda Equine Syndrome should be considered.

The other scenario where, the diagnosis may be late, is in the elderly, who may present with new onset of falling over, or unsteadiness. There are numerous causes of this, and weakness in the legs may not have been documented. Ideally, all such patients who present “off their feet” should have a neurological assessment, that should include testing sensation in the “saddle area”, checking that there is no urinary retention, and whether there is loss of anal tone (by performing a rectal examination). The clinical examination findings need to be recorded in the notes.

The diagnosis needs to be made promptly, by either an MRI scan of the spine, CT scanning, or X ray myelogram. Urgent discussion and referral to a neurosurgical centre needs to be made, and treatment should be within 48hours. There is a maximal chance of salvaging bladder and bowel function if surgery is in that time frame.

Medico-legal issues:

  • CES is a rare condition, but prompt diagnosis and treatment needs to be expedited within 48 hours to minimize permanent neurological damage.
  • Recurring or lingering backache should raise suspicions.
  • The onset of loss of groin sensation, loss of bladder and bowel function should prompt urgent detailed clinical examination and investigation.
  • If Cauda Equina is clinically suspected, urgent radiological investigation should not have been deferred.
  • Scrupulous note keeping of clinical features in patients who have presented acutely “off their feet”, or with features of leg weakness, should be evident.

Here in the Clinical Negligence Team at Dutton Gregory, our Emily Bray was recently successful in helping a claimant secure £105,000 from the NHS for the delayed diagnosis and treatment of CES. The NHS denied liability throughout the case on the basis that they maintained that the claimant had not reported the red flag symptoms to her doctors (and hence the opportunity to treat her symptoms before CES developed was missed), an allegation that the claimant strenuously denied. The NHS was unable to produce the medical records relating to one of the appointments in question.

This was an unusual CES case as, in most; it is the medical issues which are disputed, rather than the facts of when or if symptoms were reported.

Also our Head of Department, Carol Maunder, settled a CES case in 2008 for £1.35 million. In that case, the Claimant had undergone back surgery, following which post-operative bleeding collected to form a large haematoma that compressed the spinal cord. Instead of performing further surgery to decompress the haematoma, the Claimant was treated with bed-rest in Hospital for several days, as a result of which his condition worsened, due to there being only a short window of time in which to successfully perform decompression surgery. The award was significant for this type of case, as the Claimant was a young male who suffered a substantial loss of earnings.

If you want further information about this particular topic, or wish to discuss the possibility of bringing a claim for Clinical Negligence - or indeed any other type of injury, please contact the Dutton Gregory Clinical Negligence Team on (01202) 315005, or email c.hayter@duttongregory.co.uk  

NB This article does not constitute legal advice and should not be relied on as such. No responsibility for the accuracy and/or correctness of the information and commentary set out in the article, or for any consequences of relying on it, is assumed or accepted by any member of Dutton Gregory LLP.