This article explores cauda equina syndrome and clearly demonstrates how engaging an expert with the right experience will achieve the best outcome in medical negligence cases involving this painful and extremely serious condition. Mr Patrick McKenna MBBS FRCS, Consultant Spine Surgeon and expert witness begins this article by exploring a diagnosis and description of the causes of cauda equina syndrome.
What is Cauda Equina syndrome?
Cauda equina syndrome (CES) is a rare but life-altering condition in which pressure is exerted on the group of nerves and nerve roots known collectively as the cauda equina. Its cause can be mechanical through impingement or inflammation in the area or following surgery to repair a lumbar herniated disc. It is a relatively rare condition, but when present, is a surgical emergency as the longer the nerves are compressed, the more likely the patient will suffer permanent neurological damage.
Cauda Equina Syndrome (CES) – basic facts
CES can lead to loss of control of the pelvic organs and the legs and unless the forces of compression are relieved, the patient risks permanent loss of sensory and motor control in the areas affected by the cauda equina. This means potential loss of bladder and bowel control as well as movement and sensation in the legs. Patients may also lose sexual function and sensation in the pelvic area.
Normally, peripheral nerves are protected from mechanical shocks and injury by an outer sheath of connective tissue known as the epineurium. In the case of the cauda equina nerve roots, their epineurium sheath is not as well developed and so they can be especially susceptible to injury.
In some patients, the condition starts suddenly, in others the onset of symptoms is more gradual. The extent of sensory and motor disturbance depends on the degree of compression placed on the cauda equina and the nature of the disturbance. Symptoms vary from patient to patient as does the severity, but they are likely to include some of the following:
- Weakness in the affected area, usually the legs.
- Abnormal sensations such as tingling.
- Pain. The quality and intensity of pain vary.
- Inability to stand or walk normally.
- Stiffness in the back.
- Urinary incontinence.
- Urine retention.
- Faecal incontinence.
- Loss of sexual function.
Causes of Cauda Equina Syndrome
Cauda equina syndrome is a form of neuropathy- a neuropathy is any condition that affects nerves or impairs their normal function. The damage is caused when the nerves of the cauda equina suffer compression or pinching as a result of injury, infection or even surgical complications. The damage caused may be irreversible and a patient showing signs consistent with cauda equina symptom should be treated as an emergency. Often, surgical intervention will be required to relieve the pressure on the nerves and nerve roots forming the cauda equina if there is mechanical compression of the nerves.
Diagnosis and treatment of Cauda Equina Syndrome
Successful diagnosis of cauda equina syndrome relies on fitting the clinical criteria and radiological assessment. . In view of the neurological nature of symptoms being displayed by the patient, the medical team may already be alerted to the possibility of some form of damage involving the lower section of the spine, it is important to establish what the cause is exactly and whether it might be a tumour or some other factor related to infection, surgery or existing disorder of the spine. The best way to do this is with MRI (magnetic resonance imaging) unless the patient has a contraindication to the scan, for example. has a pacemaker or spinal cord stimulator or metal fragments such as shrapnel. In these rare cases a CT myelogram may be used instead.
The sooner the problem is identified, the better the overall outlook for the patient’s survival with minimal lasting damage to the nerves. Most often, surgery is necessary for immediate decompression and surgery within a window of 24 hours following the onset of symptoms is considered to have the best prognosis for recovery of neurological function. Even with surgery, the patient will likely need intensive rehabilitative therapy and support before full function can be restored. The patient may continue to suffer with leg pain or lower back pain even after surgery and full recovery depends on the extent of damage sustained and other factors such as the general health of the patient.
In this case, the claimant (a young woman) suffered cauda equina syndrome as the result of delayed spinal surgery. The claimant ran her own business and was a mother to young children. The claimant suffered from lower back pain for some years and whilst away on a short-break with relatives suffered an acute and severe episode of back pain, so painful she was taken to hospital by ambulance.
Despite the treating clinicians diagnosing a possible nerve root compression from a disc prolapse and recommending an MRI be carried out she was later released from hospital without undergoing the MRI.
Her condition deteriorated overnight, her GP was called and he arranged for her to be transported back to hospital with a diagnosis of suspected cauda equina syndrome. An MRI scan identified a massive prolapsed disc at L5/S1 obliterating the spinal canal, and the claimant underwent emergency spinal decompression surgery.
The delay in the diagnosis and treatment of the Cauda Equina caused severe injuries to the claimant including bowel and bladder incontinence, loss of sexual sensation, and weakness in her leg, all of which impeded her life, future prospects and earnings. She was awarded a significant sum by the Court.
Consulting with the right expert provides the benefit of securing the best and most compelling expert opinion to support your case or defend it. Especially in a case like this where there is a wide range of opinion from within the spinal world as to what the definition of cauda equina syndrome is, and the strength of the evidence base around timing and impact of surgical intervention.