What is Cauda equina syndrome? A medical negligence lawyer explains

What is Cauda equina syndrome? A medical negligence lawyer 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. Medical Negligence Solicitors believe that those affected by medical accidents deserve an honest, straightforward and appropriate explanation, support and compensation at a fair and just level.

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