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A Sting in the Tail - What to look for in a Cauda Equina Syndrome Case

Cauda Equina syndrome is a rare and severe type of spinal stenosis. It occurs when the nerves in the lower back become severely compressed. It's sometimes a result of a prolapsed disc bulge and requires urgent hospital admission and timely surgery. The longer it goes untreated, the greater the chance it will result in permanent paralysis and incontinence.

The Nice Guidelines were updated in December 2020, and are more comprehensive. The additions have been made in bold.

Red flags include ;

• bilateral sciatica;
• difficulty passing urine or impaired sensation of urinary flow;
• loss of sensation of rectal fullness;
• loss of sensation in the saddle;
• laxity of the anal sphincter;
• motor weakness in the legs manifesting as knee extension, ankle inversion or foot dorsiflexion.

Consequently, there is greater pressure on the staff taking initial history. More subtle symptoms now have weight.

The seriousness of the condition depends on the stage that has been reached; Suspected (CES-S) , incomplete (CES-I), Retention (CES-R) and Complete (CES-C) Patients deteriorate at varying rates. Usually, the outcome of surgery for patients with CES-I is good, but it is poor for patients with CES -R.

Once suspected an MRI scan should be performed. If Cauda Equina Syndrome is found, decompression surgery is required as soon as possible ( or as soon as is reasonably possible). In legal terms, it's important to see on the facts which stage has been reached and how quickly it is acted upon. A lot can be learned from slight alterations in condition and there is a need for special care in history taking.

In the case of Hewes v West Hertfordshire Hospitals NHS Trust (2020), Davies LJ suggested; "what is ordinarily required, in each case, is consideration of whether the responses and procedures actually undertaken in a given medical situation fall out with the range of reasonable and logically justifiable responses and procedures applying the Bolam/Bolitho principles, on the facts of the individual case."

The success of surgery depends on the neurological condition of the patient at the time of surgery. There there is often conflict around the passage from CES-I to CES - R.

When looking at a case it is for the solicitor to consider;

1. Context
2. The symptoms present at presentation should be cross referenced and considered against the medical records
3. The 2018 Nice Guidelines lower the threshold for seeking specialist advice and border on saying single "you suspect CES, you are scanned for it." It would imply the MRI must be available at the hospital 24 /7. It also makes it clear that MRI for suspected Cauda Equina Syndrome must take precedence over routine cases. This requirement is likely to have resource implications but is good news for patients and for patient safety.
4. There should be a Cauda Equina Syndrome timeline, which studies the sliding scale presentation.
5. It is for the Claimant's Solicitor to focus on the window of lost opportunity.

For more information contact Leonie Millard in our Clinical Negligence department via email or phone on 01254 770517. Alternatively send any question through to Forbes Solicitors via our online Contact Form.

Learn more about our Clinical Negligence department here

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