Cauda Equina Syndrome
Cauda Equine Syndrome is caused by significant narrowing of the spinal canal that compresses the nerve roots below the level of the spinal cord. One of the more common causes of Cauda Equina Syndrome is during surgery to the lower back. In some cases, this surgery can lead to a medical negligence claim.
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Cauda Equine Syndrome can be caused by the following:-
- Traumatic injury;
- Slipped or prolapsed discs;
- Spinal stenosis (narrowing of the normal front to back distance of the spinal canal);
- Spinal tumours;
- Inflammatory conditions;
- Infectious conditions;
- Through medical intervention such as surgery.
Symptoms Of Cauda Equina
The symptoms of Cauda Equine Syndrome include the following:-
- Low back pain
- Pain in one leg or both legs but starts in the buttocks and travels down the back of the thighs and legs
- Numbness in the groin
- Bowel and bladder disturbance
- Lower extremity muscle weakness and loss of sensation
- Reduced or absent lower extremity reflexes
Recognition of Cauda Equine Syndrome is often delayed as it presents with bladder, bowel and sexual problems which are common complaints and can have a variety of causes. Also, patients may not mention some of these symptoms because they are embarrassed about them. For clinicians it is important to document the nature and timing of bladder, bowel and sexual symptoms particularly if they are new and especially in those with a history of back pain and associated leg pain and to make a timely referral for proper investigation and expert treatment.
The 'red flag' symptoms for Cauda Equine Syndrome are the following:-
- Severe low back pain;
- Sciatica;
- Saddle and genital sensory numbness;
- Bladder, bowel and sexual dysfunction;
- Has not passed urine for 6 – 8 hours.
In terms of management of the Cauda Equine Syndrome, it is important for the clinician to establish whether the syndrome is complete or incomplete. Where it is incomplete the patient has one or more of the following symptoms:-
- Altered urinary sensation;
- Loss of desire to void;
- Poor stream or the need to strain.
Where the syndrome is complete, the patient experiences painless urinary retention and overflow incontinence.
Cauda Equine Syndrome generally requires urgent surgical treatment. The longer the compression continues, the more likely there is to be long term neurological damage. In 50% of cases it will be too late after the first 4 – 6 hours of a severe central disc prolapse resulting in complete Cauda Equine Syndrome. In those cases therefore there is a very small window of opportunity in which to achieve a referral to an appropriate hospital, confirm the diagnosis by MRI scan and then proceed to a surgical decompression.
Where a patient has clinical features of Cauda Equine Syndrome and the MRI scan shows a potentially reversible cause of pressure then surgical decompression is recommended. This operation is complicated and demanding and it carries a risk of further damage to the nerve roots.
One review which has been undertaken and which has been widely quoted suggests that intervention less than 48 hours after the onset of symptoms produces a better outcome than intervention delayed for longer than this. Another view is that the outcome for both types of Cauda Equine Syndrome, namely with retention of urine or incomplete retention, is better with surgical intervention within 24 hours. It was noted that of 47 patients having surgery within 24 hours, 87% recovered normal bladder function whereas, of 46 patients having surgery later than 24 hours, only 43% recovered normal bladder function.
It would seem that early surgery is related to better results where a patient has incomplete Cauda Equine Syndrome but the case for Cauda Equine Syndrome with retention of urine is less certain.
The common causes of delay in diagnosing and treating Cauda Equine Syndrome are:-
- Patients who delay in seeking medical help;
- GPs not recognising the 'red flag' symptoms;
- Junior accident and emergency staff misdiagnosing the condition;
- Junior accident and emergency staff not calling for a consultant;
- Hospital delays in admission to surgical units and in arranging MRI scans and surgery within an appropriate period and conducted by a suitably experienced team;
- Failure to warn of neurological damage prior to surgery for Cauda Equine Syndrome;
- Deficiencies in after care.
Most patients are young to middle aged and working before they develop Cauda Equine Syndrome. Their residual symptoms often mean that they are unable to work and that they have genito-urinary and bowel symptoms. From 1997 to 2006 the NHS dealt with 107 cases in England in which patients with Cauda Equine Syndrome have been compromised by their care in hospital.
Cauda Equine Syndrome is a relatively rare condition. There are only about 100 new cases of this syndrome annually in England but it is estimated that at least 10% of these are mismanaged and involve litigation against the NHS.
Of those cases which were litigated between 1997 and 2006, in 35% of cases the primary complaint was against the accident and emergency department and in 52% against the in-patient management team.
Summary
If you or someone you know is suffering from or has suffered from Cauda Equina Syndrome following surgery you should seek expert medical advice from a medical negligence solicitor.
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