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Cauda Equina Syndrome – know the symptoms and act quickly

Insights / / Bristol

Frances Wright, Clinical Negligence Specialist Solicitor at Ince Metcalfes explains Cauda Equina Syndrome (CES), and how the rare and devastating condition can be prevented if recognised quickly. 

Cauda Equina is Latin for “horse’s tail” and is the term used for the bundle of nerve roots at the lower end of the spine. These nerves control sensation and function for the saddle area (upper thighs, groin and bottom), bladder, bowel and legs. Cauda Equina Syndrome (CES) occurs if the nerve roots are subjected to sustained pressure, for example from a herniated (or “slipped”) disc. Other potential causes are spinal stenosis (narrowing of the spinal canal), infection and inflammation. If the source of pressure is removed within 48 hours of onset of symptoms, there is a chance for the nerves to recover.

Case study

Tom* was a 53-year-old painter and decorator who consulted his GP when he developed severe pain in his lower back, running down his right leg. His GP sent him for a scan which showed he had a herniated lumbar disc. She referred him to the Musculo-Skeletal Clinic and told him to go straight to the Emergency Department at the hospital if he should develop saddle numbness or have any problems urinating or defecating. A week later, Tom noticed that he could not feel anything when he wiped himself after going to the toilet, and that he could not urinate. He went to the Emergency Department at the hospital and was seen by a junior doctor. He explained his symptoms, and the doctor reassured him that it was safe to wait for his clinic appointment later that week.

Four days later, Tom was seen at the clinic. He was immediately referred to the hospital for neurosurgical assessment and diagnosed with CES. He underwent spinal decompression surgery but by now, the nerve damage was irreversible. 

Tom has been left with groin numbness and poor bladder function which means he has to self-catheterise. He has foot drop which makes it difficult for him to run or to manage stairs. His marriage suffered, he could not work properly and, unsurprisingly, he became depressed.

Tom’s surgeon told him that if CES had been diagnosed when he attended the Emergency Department, surgery would have been done within 24 hours and he would not have suffered permanent nerve damage. 

Red flags

Signs and symptoms of CES usually start suddenly and progress rapidly, although they can come on gradually. They include:

  • Intense lower back pain;
  • Pain, loss of sensation, weakness and altered reflexes in one or both legs;
  • Altered sensation such as pins and needles or numbness around the anal/saddle area;
  • Bladder problems: difficulty passing urine or incontinence;
  • Altered bowel function: constipation or incontinence; and
  • Altered sexual function, usually impotence in men.

These red flags require immediate medical advice and hospital referral for specialist examination and MRI, CT and bladder scans. Referral needs to happen within hours rather than days - as there is only a 24-48 hour window for surgery to prevent permanent damage.

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*Pseudonyms have been used in this article to protect the client’s identity.

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