Cauda Equina Syndrome (‘CES’) is a thankfully rare condition but one with a disproportionately high medico-legal profile. That high profile comes from the substantial levels of compensation that claims of this nature attract, compensation that reflects the damaging and distressing nature of this condition.
So what is CES?
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”. It refers to the normal anatomy of the end of the spinal cord in the low back. This is where the spinal cord divides into many bundles of nerve tracts and resembles 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 most frequently occurs following a large lower lumbar disc herniation, prolapse or sequestration.
How is CES diagnosed?
CES is usually diagnosed in the presence of the following, so called, ‘red flag’ symptoms:
- Severe low back pain.
- Sciatica – often bilateral but sometimes absent.
- 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 other ‘red flag’ symptom(s) must trigger immediate action, generally involving emergency referral to an accident and emergency department with ready access to a spinal surgery unit. Prompt MRI scanning confirms the diagnosis, and 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 backache 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).
‘Incomplete’ or ‘with retention’ – the key to most cases:
Although the description above 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 perineal sensation and urinary function.
When the syndrome is incomplete (‘CES-i’), the patient has urinary difficulties of neurological origin. These difficulties can include altered urinary sensation, loss of desire to void, 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 reason why this distinction is key is that 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.
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, confirm the diagnosis by MRI scan and then surgically decompress the nerves. In many cases the Defendant can argue that any delay on their part would not have changed the outcome in any event.
The situation with regards to CES-i is, however, very different.
Here the window of opportunity can extend over a much longer period, days or weeks. Prompt treatment offers a good prognosis. The important issue is to avoid CES-r. Punctual 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 very damaging, condition.
It is a tragedy, often avoidable, if an incomplete syndrome becomes complete when under medical supervision.
CES occupies a prominent position in the medico-legal field, partly perhaps through a lack of awareness and urgency in its management, and partly because of the devastating consequences of inadequate management. CES-r often results in constant pain, bowel, bladder and sexual and lower limb dysfunction. In my experience it is also a condition that disproportionally affects the young.
Compensation levels very. The industry accepted norm seems to be somewhere between £600,000 and £800,000 per claim.
Compensation levels should only ever be properly determined by reference to the extent of injury and personal circumstances. That said a further factor might also be the experience and quality of the legal advice given. The most recent claim I pursued settled for £2.9 million – somewhat above the national average. For anyone affected by CES the message is clear, top quality legal advice can make all the difference.
At Davies and Partners we have a team of specialist clinical negligence solicitors covering most of the UK (from my base in North Devon to our offices in Bristol, Gloucester, Birmingham and, of course, London). Whilst we each have areas of medicine that we particularly specialise in, what unites us is our quality and commitment to excellence.