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Cauda Equina Syndrome : ensuring early diagnosis to improve outcomes

In my professional role I have acted for a number of clients making claims involving negligent treatment for cauda equina syndrome.  Whilst I read in a recent Trauma and Orthopaedics article by Professor Jeremy Fairbank that, in England alone, 1000 operations are done each year for cauda equina syndrome, it is still a rare condition and most GP’s will probably only see 1 or 2 cases in their practicing career. Nevertheless, the effects of the syndrome on patients are devastating and all doctors should be alert to the possible symptoms and how to treat accordingly.

What is cauda equina syndrome

Cauda equina syndrome is caused by narrowing of the spinal canal (‘stenosis’) which compresses the nerve roots below the level of the spinal cord. These roots look like a horse’s tail at this point, hence the name given to them of ‘cauda equina’. It is usually considered a medical emergency as a failure to act at the earliest opportunity can leave a patient with permanent and severe disabilities.

Causes of cauda equina

There are a number of causes of cauda equina such as:

• disc herniation
• spinal stenosis
• traumatic injury
• spinal tumours
• A collection of blood in the spinal canal surrounding the nerves
• Spondylitis
• A fracture/dislocation of the lower back which can then result in compression of the cauda equina.

What are the symptoms?

Whilst not intended to be an exhaustive list, symptoms of cauda equina syndrome can include:

• Sciatica (Low back pain or pain which may extend to the buttock causing numbness).
• Bowel and/or bladder dysfunction (such as loss of anal tone and sensation, incontinence, inability to urinate or increased urgency to urinate).
• Acute or chronic radiating pain.
• Numbness and/or weakness in legs.
• Numbness in Saddle/perineal region.
• Sexual dysfunction that has come on suddenly.

Although symptoms such as low back pain are often caused by simple disc herniation, which does not require urgent attention, if patients develop severe pain/loss of sensation they should contact a medical practitioner immediately.

Investigations, diagnosis and treatment

If cauda equina syndrome is suspected, the GP/medical practitioner should base their findings from the patient’s medical history, symptoms and physical neurological examinations.  The physical examination can consist of testing muscle strength and reflexes in the legs and feet, evaluating sensation to touch/pain and an internal rectal examination to test anal tone.

If the tests indicate a diagnosis of cauda equina syndrome then the patient should be referred immediately for an MRI scan.

An MRI scan is vital in diagnosis of cauda equina syndrome and arguably needs to be available immediately at every hospital. Professor Fairbanks shares this view in his article and thinks that the cause and level of the spinal pathology can only be established with an MRI scan therefore hospitals providing emergency care need access to out of hours MRI scan available 24 hours a day, 7 days a week to ensure there are no delays and an immediate MRI can be carried out.

Once a diagnosis of cauda equina syndrome is made, urgent decompression surgery needs to be carried out to release the compression of the nerves. Any delay in treatment may result in symptoms becoming permanent and therefore urgency is imperative.

The timeframe for decompression surgery is a matter of differing opinion from experts in this area. Although many experts agree that there is a window of 24-48 hours from the onset of the patient’s symptoms for surgery to be carried out, Professor Fairbank and Professor Kohles are of the view that if surgery is carried out within 24 hours, the patient will have a better outcome. Whatever the precise timeframe, it seems to be generally agreed that sooner rather than later is always better.

Our experience

As clinical negligence solicitors, I and my colleagues all too often see patients who have suffered due to delayed diagnosis or delay in receiving treatment for cauda equina syndrome and the results for them and their family can be devastating.

Unfortunately delays do occur and in the majority of the time, this is due to the GP or accident and emergency practitioners who fail to recognise the red flag symptoms of cauda equina syndrome and accordingly fail to refer the patient for further investigations (including MRI scan) which then leads to a delay in diagnosis and the patient having surgery.

Where such delays have resulted in the patient suffering from ongoing symptoms or permanent disability, the patient can make a negligence claim for compensation.  These claims are usually for significant sums because many patients are left with ongoing and permanent symptoms, including bowel/bladder/sexual dysfunction, which have a serious impact on a patient’s life. Where patients of working age are left with permanent symptoms this can impact on their ability to work and therefore making a claim is essential to ensure the patient is able to financially support themselves and their family.

The warning signs of progressive neurological deficit are frequently missed and awareness needs to be raised among medical staff.

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