Legal Cases In Cauda Equina Syndrome - The Underlying Causes

Cauda Equina Syndrome is an evolving condition which gets progressively worse, usually relatively quickly (known as acute CES) but sometimes relatively slowly (known as chronic CES).

This arises because some clinicians are looking for, and warning patients about, much later extreme symptoms such as urinary and or faecal incontinence or retention, total loss of sexual pleasure, and inability to walk. However, by the time patients have these Cauda Equina Syndrome Retention (CESR) symptoms, the prospect of full recovery through emergency MRI scan to confirm the CES diagnosis, followed by a timely decompression operation, have greatly diminished. For if surgery is delayed more than 24 hours from the onset of Cauda Equina Syndrome Incomplete (CESI) symptoms, the result is significantly worse, and even worse still if the results are delayed for greater than 48 hours from the onset.

Cauda Equina Symptoms

In contrast, the most common initial CES symptoms are perineal paraesthesia, together with altered bladder and anal function, and bilateral lower leg pain, paraesthesia, and motor power abnormality. These Cauda Equina Syndrome Early (CESE) or Cauda Equina Syndrome Incomplete (CESI) symptoms usually develop from unilateral symptoms.  To achieve timely diagnosis, clinicians should consider the possibility of CES when some, but not necessarily all, of these characteristic symptoms are present, especially when they progress from unilateral to bilateral, and arrange an emergency MRI scan accordingly.

An example would be a female patient with severe back pain having difficulties over a 24 hour period on a Sunday urinating and also starting to notice a different sensation in the vaginal area when wiping.  At an appointment with the GP on the Monday, these symptoms alone should warrant immediate referral to the Hospital for an emergency MRI scan with or without the GP noting any other CES symptoms at the time.

Clinicians should also warn patients about these early symptoms and advise immediate attendance at hospital if they occur. In the above example the female patient if so advised would have made her own way to hospital on the Sunday and received earlier treatment which would be likely to be more successful.

A frequent cause of Cauda Equina Syndrome court cases against hospitals is that some still do not provide a radiological service able to perform spinal MRI scans “out of hours”, 24/7.

So, for example, the female patient described above could arrive at hospital at say at noon on Monday, then say wait to be seen six hours in A & E, be diagnosed with possible CES, but then have to wait until the next morning for a scan to confirm this, followed by an operation that afternoon to decompress her cauda equina, but by which time it is too late, as over 48 hours have passed since onset of her CES symptoms and unfortunately she is now CESR.

Cauda Equina & Breach Of Duty

It must be borne in mind that establishing breach of duty by either the GP or the hospital doctors in such cases is not a given, bearing in mind that real world evidence suggests bladder symptoms are frequent complaints in spine patients without CES. Also waiting to be seen six hours in A & E department might be considered reasonable as we all know that they are now usually very busy.

However, breach of duty against the GP might be established for failing to give the patient CES red flag warning advice (“safety netting”) if for example she had seen the GP on the preceding Friday complaining not just of severe back pain but of sciatica, unilateral or bilateral.

Also, after possible CES diagnosis at the hospital, perhaps after a perineal examination confirms objective numbness, or a bladder scan pre and post urination revealing a high residual volume, there would likely be breach of duty in such a case as the patient should have been transferred to a specialist hospital where they are able to both MRI scan the spine to confirm cauda equina compression, and then operate during the night.

Regarding a Cauda Equina Syndrome lawsuit involving slow onset CES, the slow, chronic progression and varying presenting signs and symptoms of slow onset CES often mimic mechanical low back pain and makes the diagnosis difficult in its early stages. Rather than sacral signs such as perineal numbness together with urinary frequency and urgency, because of the location of the herniation in conjunction with degenerative changes at other levels of the lumbar spine such as spinal stenosis, some patients may exhibit early lumbar radicular signs such as lower limb weakness, sensory deficits along dermatomal distributions, diminished deep tendon reflexes and referred pain patterns.

Next Steps

For further advice and/or an initial discussion on pursuing a Cauda Equina Syndrome claim, please feel free to contact me on freephone 0800 011 6666 or via email at legal@timms-law.com. For more information visit the Cauda Equina section of our website.