Cauda equina syndrome (“CES”) is a medical emergency.
Any delay in diagnosis and treatment of CES can result in life-changing physical disability and psychological injury.
What is cauda equina syndrome (CES) exactly?
CES is an uncommon but serious neurological condition.
It is caused by compression (i.e. squeezing) of a bundle of nerve roots at the base of the spinal column.
Cauda is Latin for tail and equina is Latin for horse (ie, the “horse’s tail”). The seat of the problem is around where your tail would connect to your body, if you had a tail.
The ‘cauda equina’ nerves provide feeling to, and enable control of, the bowel, bladder, anal and genital areas. Also, the legs and feet. So it all sounds quite crucial, doesn’t it?
Compression of these nerves – say, as a result of a slipped disc or lower back injury – puts the injured person at risk of permanent disability.
Someone with suspected cauda equina must be referred for urgent assessment.
Typically, this will include an MRI scan and neurosurgical review.
If necessary, emergency surgery (to release the pressure on their spinal cord) will follow as soon as possible.
CES is a topical ‘health and safety’ issue.
In 2021, the Healthcare Safety Investigation Branch (HSIB) produced a national learning report, entitled Timely detection and treatment of cauda equina syndrome.
The report was looking at lessons which could be learned from a specific healthcare incident.
This concerned the case of a 32-year-old woman who was left with permanent back pain and neurological symptoms, despite comprehensive rehabilitation efforts.
Her symptoms included increasing pain in her pelvis, abdomen and back. This discomfort radiated down her leg and into her calf. She also had one episode of urinary incontinence (a “red flag” symptom of CES).
She had been subjected to various delays, as follows:
- in obtaining an MRI scan,
- in onward referral to a regional specialist spinal centre,
- in obtaining neurosurgical review, and
- in decompression surgery for CES being done.
This case highlights the additional issue of “remoteness” (from regional, specialist hospitals) of places like Moray and why early diagnosis of possible CES is so crucial in more rural areas where some “delay” (say, in getting to Aberdeen or Inverness) is going to be an inevitable part of the treatment process.
National standards set out the danger signs which show that CES should be suspected.
The guidelines describe “at risk” patients as those who present:
- with back pain and/or sciatic pain
- with any disturbance of their bladder or bowel function
- with saddle or genital sensory disturbance or
- with bilateral leg pain.
Diagnosing CES is not straightforward.
It’s a rare condition.
Many doctors will never have encountered it before. Patients don’t always describe the length or nature of their symptoms clearly. And GP consultation slots are brief, not easily allowing enough time for a full clinical examination to exclude other possible causes of lower back discomfort.
“Red flag” signs and symptoms are easy to specify in theory but may often be rather blurred in practice. Some CES indicators – e.g. bladder or bowel symptoms – are linked to other conditions too.
Another problem with red flag symptoms is that they may show up “too late”.
By the time possible CES indicators such as incontinence appear, this may already be evidence that the person has suffered neurological damage which will not be reversible.
One of the discussion points from the HSIB report is whether a more helpful approach for the future might be to have guidance setting out early features of CES rather than possibly-too-late-to-avoid-permanent-injury red flags.
We’ve seen CES develop or at least be suspected against a range of different background facts.
In one case, a client developed CES after falling from a horse.
In another case, the client had suffered serious lower leg injuries in a road traffic accident. Their recovery was slow and their walking gait altered as a result of ongoing lower limb pain. Over time, this caused lower back pain to appear and a suspicion of CES, though this proved, fortunately, to be unfounded.
Lower back pain is a common issue.
It also has a wide range of different causes.
As we have seen, CES is a dangerous condition which can appear suddenly and where the window of opportunity to prevent permanent injury is short – days, at most. The long-term consequences of CES can be most unpleasant and have a significant impact on your quality of life – e.g. permanent leg pain and incontinence problems.
How we can help
We hope we’ve convinced you why knowing about Cauda Equina Syndrome – and perhaps even naming it to your GP against a background of relevant symptoms – could be crucial to your future health or that of a loved one.