Preventing the ticking time bomb of CES
Before working in the Spinal Injury team here at BBK, I had never come across Cauda Equina Syndrome (CES). Similarly many of our clients had not heard of it either until they experienced it themselves. Unfortunately, it seems to be an area in clinical negligence in which the same failures repeatedly occur leaving our clients with permanent life-changing injuries. CES is such a time sensitive condition that the medical profession need to ensure urgent treatment is being provided to those with suspected CES before it is too late. The Spinal Injury team has a wealth of experience in handling CES claims and getting the best level of compensation for our clients who have really suffered through negligence that could have easily been avoided.
What is cauda equina syndrome?
The cauda equina is the name of a group of nerves located at the lower end of the spinal cord. CES is when these nerves suddenly become severely compressed.
This is most commonly due to a severe ruptured disc, spinal stenosis, a spinal lesion, a spinal infection or from a severe lumbar spine injury.
Symptoms of CES can be;
- Bilateral sciatica (occurring on both sides)
- Increasing severe weakness or numbness in both legs
- Numbness around your genital region or perineum and the inner thighs
- Urinary and/or faecal incontinence
Diagnosing cauda equina syndrome
If CES is not caught early it can lead to life-changing injuries such as severely impaired mobility, incontinence and nerve damage. The difficulty is that its diagnosis can be tricky as CES often begins with back pain and features of sciatica which, unlike CES, are fairly common and most people will experience it in their lives. The prejudice surrounding back pain makes it all the more difficult and it is important that if a patient presents to their GP or to A&E with lower back pain and sciatica they must be assessed as being potentially at risk of developing CES.
To rule CES out, or indeed diagnose it, it is important that an MRI scan is undertaken as a matter of urgency and in any event, within a few hours of the patient presenting to hospital with new-onset urinary symptoms and associated back pain or sciatica. The MRI will be able to show the compression and the patient will then likely be listed for urgent decompression surgery following a neurological examination.
However, this does not always happen. Sometimes the patient will go into the hospital and have to wait for a long time to be assessed by the spinal team (often a neurosurgeon or a spinal surgeon). The reliability of the clinical diagnosis of CES without an MRI is low and the patient may be sent away. Alternatively, the patient might be put on the list for an MRI but this could take days or weeks in which time the CES has developed and it is too late.
An early diagnosis and surgical decompression will usually result in a favourable outcome and the patient will be less likely to experience some of the long-lasting symptoms of CES. However unfortunately, it is not uncommon for CES to go undiagnosed until it has passed the point of a good recovery. Many of our clients have had either a delayed MRI scan or delayed surgery which has had a significantly negative impact on their injury and has led to a worsening of their condition including permanent limb paralysis and a permanent loss of bowel, bladder and sexual function.
For one of our clients, an increase in her back pain and bilateral sciatica coupled with numbness and urinary issues meant that her GP urgently referred her to hospital. A neurological assessment was performed at hospital and it was concluded that she did not require an urgent MRI. She was sent home and referred for an MRI on an out-patient basis. The MRI did not take place until 6 days later which showed that her cauda equina nerves were compressing. Despite this finding, the surgery was not booked in until 6 days later. It was then cancelled and a further surgery was scheduled which took place 8 days after the initial surgery was booked in. Unsurprisingly, despite undergoing the decompression surgery my client was left with complete CES and an impairment in her bladder function and sexual function. Had she undergone the emergency MRI and the surgery promptly, it is very likely she could have avoided this and made a good recovery.
Preventing cauda equina syndrome
To prevent this, it is important that patients should be advised by their GP to go to A&E if they begin experiencing any of the CES symptoms listed above. When they arrive in A&E, they should be seen promptly and the consultant should receive advice from an orthopaedic surgeon or a neurosurgeon. They should then be sent for an MRI no matter what the time or day is – CES can occur very quickly and there should be no delays in its diagnosis.
We would encourage GP’s and hospital trusts to create and follow pathways for suspected CES patients. This in turn would prevent delayed or missed diagnoses of CES and result in a better outcome for the patient.
Trusts should ensure that;
- All hospitals in their trust has the availability for out of hours MRI scans
- The need for a discussion with the local spine services prior to performing the MRI is removed
- Senior doctors in A&E can request the MRI to reduce delays by having the orthopaedic or neurosurgeon assessing the patient first
- The MRI should always be undertaken as an emergency and take over any routine cases
- The MRI and the subsequent CES diagnosis should be achieved before the discussion with spinal services
Whilst we are proud of our success in proving that the CES was caused by negligence, we would ultimately like to see a better understanding of this syndrome across the NHS. Consideration should be given to better education for frontline healthcare professionals and lowering the threshold for scanning potential patients.