What is cauda equina syndrome?

Cauda equina syndrome (CES) is a condition that occurs when the nerves at the base of the spinal cord are compressed. It can come on suddenly, and usually requires emergency surgery. Early diagnosis and treatment are vital for the best chance of recovery as, if left untreated, CES can result in permanent paralysis as well as incontinence.

‘Cauda equina’ means ‘horse’s tail’ in Latin. It’s used to describe the collection of nerves at the base of the spine because the nerves there fan out to resemble a horse’s tail. These nerves send and receive messages to and from the legs, feet and pelvic organs. If they become squashed, it can cause pain, numbness and weakness in the legs and feet, as well as issues with bladder and bowel control and difficulty with sexual function.

How rare is cauda equina syndrome?

Cauda equina syndrome is a rare condition, occurring in only one to three in every 100,000 people. It’s not linked to gender or race, and, although it mostly occurs in adults, it can affect people of all ages. However, if you have a herniated lumbar disc, you’re at higher risk as up to two people in every 100 with the condition develops CES.

What causes cauda equina syndrome?

The most common causes of cauda equina syndrome are:

  • Severe herniated disc in the lumbar area
  • Lumbar spinal stenosis, which is a narrowing of the spinal canal
  • A spinal lesion or malignant tumour
  • Spinal infection, inflammation, haemorrhage or fracture
  • A lumbar spine injury such as a car crash, fall, gunshot or stabbing
  • A birth defect such as arteriovenous malformation (an abnormal connection between blood vessels)
  • Postoperative complications following lumbar spine surgery
  • Spinal anaesthesia

What are the symptons of cauda equina syndrome?

It can sometimes be difficult to figure out if you have CES, as it has a range of symptoms that mimic those of other conditions. Symptoms can also vary in intensity depending on the exact location and degree of compression. You should also be aware that symptoms can either develop rapidly within 24 hours, or gradually progress over weeks or months. During this period, cauda equina symptoms can come and go. For these reasons, and because it’s not often seen in practice, CES can be hard to diagnose and is often misdiagnosed.

Some of the symptoms to look out for that might indicate CES include:

  • Severe lower back pain
  • Weakness, numbness or pain in one, or, more commonly, both legs
  • Saddle anaesthesia – numbness in the areas that would have regular contact with a saddle when riding a horse
  • Recent issues with your bladder or bowel such as difficulty eliminating urine or faeces (retention) or difficulty holding it (incontinence)
  • Sensory abnormalities in the bladder or rectum
  • Recent issues with sexual dysfunction such as inability to achieve an erection or ejaculate or loss of sensation during intercourse
  • Loss of reflexes in your arms and legs

How is cauda equina syndrome diagnosed?

It’s important to treat CES early, so a quick and accurate diagnosis is key. The sooner a diagnosis can be confirmed, the better chance the patient will have to make a full recovery.

Your doctor will typically request an MRI (magnetic resonance imaging) scan as it’s the only way to definitively confirm or deny a CES diagnosis. The scan produces three-dimensional images of the spinal cord, nerve roots and surrounding areas to show the presence of cauda equina syndrome. Your doctor will use these scans to plan your treatment.

Before they order the MRI scan, your doctor will take a full medical history and do a physical examination to test the stability, strength, alignment and reflexes of your legs and feet. They may also order other diagnostic imaging tests such as a CT (computed tomography) scan or a myelogram which is an X-ray of the spinal canal following injection of a contrast dye.

What treatments are available for cauda equina syndrome?

If your doctor confirms you have CES, they’ll usually recommend emergency decompression surgery. The goal is to relieve pressure on the cauda equina nerves and to reverse the symptoms of neural dysfunction. Ideally the surgery should be done within 24 hours of the onset of serious symptoms as this gives the maximum potential for recovery. That said, patients who receive treatment after 48 hours can still experience significant improvement in their symptoms.

Depending on the underlying cause of the CES, you may also require further treatment. For example, patients who have inflammation may be prescribed anti-inflammatory agents and corticosteroids. You may be given antibiotics if you had an infection, and, if the CES was caused by a tumour, you may need radiation or chemotherapy.

After surgery, some patients may notice an immediate improvement in some or all of their symptoms. Others will find that symptoms will gradually improve over time, and this can sometimes take years.

You may be given or able to access further support such as physical therapy to help regain strength, occupational therapy to help you carry out everyday activities, and specialist help for incontinence and sexual dysfunction.

In the long-term, cauda equina syndrome does go away for some patients, although it may take years to make a full recovery. You should also be aware that, even with immediate treatment, some patients may not regain complete function.

Living with cauda equina syndrome

For patients left with long-lasting damage, cauda equina syndrome is a disability. They may no longer be able to work because of severe pain, motor weakness and sensory loss. They may also experience conditions that make their previous work life, relationships and social life difficult, such as incontinence or sexual dysfunction.

CES can also have a serious effect on a person emotionally. They may suffer from depression and require counselling to help them cope and adjust. If they have been left disabled due to a delayed diagnosis or misdiagnosis, they may also feel a lot of anger.

If you’ve been left with long-term disabling consequences due to medical negligence when treating cauda equina syndrome, you may be able to make a spinal injury claim for compensation. Below is a case study of how we helped a client with a cauda equina syndrome compensation claim.

£290,000 for student nurse who suffered a serious spinal injury at work

We acted for a student nurse who injured her back at work on a very busy, chronically-short-staffed ward. She slipped on a wet floor and injured her back, developing cauda equina syndrome. Gradually, her symptoms worsened, leaving her with numbness in the lower part of her body and an inability to pass urine. She underwent emergency decompression surgery, but there was unfortunately a delay in her treatment. She was left with permanent injuries, including needing to self-catheterise and use medication to open her bowels. We consulted with an expert in spinal injury who stated that the delay in surgery led to her CES becoming more severe. We were able to obtain £290,000 in compensation for our client, including interim payments while the case was progressing.

£1 million settlement for negligence leading to cauda equina syndrome

Our client underwent a spinal decompression operation. Her neurological presentation later deteriorated with a loss of sensation in her legs and saddle area. Her surgeon ordered an MRI scan, booked to take place four days later. Another doctor noticed her deterioration, accelerated her MRI scan and it was discovered that our client had a cauda equina spinal injury.

She has incomplete paraplegia, mobility issues, bladder and bowel dysfunction and psychological complications. She lost her independence and became reliant on her husband, paid assistance, family and friends to assist her.

Liability and causation were strongly disputed throughout this claim. Despite the fierce resistance, we fought through to a positive conclusion.

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