Tim Deeming, Partner in Tees’, Top Tier Legal 500 Medical Negligence and Personal Injury team, highlights ‘red flag’ symptoms and signs, and the importance of urgent medical intervention for patients showing symptoms of Cauda Equina syndrome. Sadly, if the warning signs are missed, it can have life changing impacts for the patient and their family and lead to a medical negligence claim.
- What is Cauda Equina Syndrome (CES)?
- What are the risks of delayed diagnosis or misdiagnosis of Cauda Equina Syndrome?
- What are the ‘red flag’ symptoms and signs of Cauda Equina Syndrome?
- What are the most common causes of cauda equina syndrome?
- How is Cauda Equina Syndrome treated?
- Common medical negligence claims relating to Cauda Equina Syndrome
- How we can help
- No win, no fee
In August 2021, the Healthcare Safety Investigation Branch (HSIB) reported their results of a national investigation into the timely detection and treatment of non-malignant spinal cord compression (cauda equina syndrome). The investigation was launched after HSIB identified an event where a patient had several GP and hospital presentations before CES was diagnosed. Once an MRI scan identified the cord compression, there were further barriers to receiving timely emergency surgery to alleviate the compression. This investigation focused on: assessing the resilience, consistency and reliability of the pathway(s) for patients experiencing potential red flags for CES; seeking to understand the context and contributory factors influencing the pathway for patients with CES from their first presentation
reviewing the national context surrounding the timely detection and treatment of spinal nerve compression (CES) in patients with back pain.
Cauda Equina Syndrome, or CES, is a potentially devastating condition caused by compression of the group of sensitive nerves located at the base of the spinal cord involved in lower limb sensation and pelvic function known as the Cauda Equina. It can result in bowel, bladder and sexual dysfunction as well as lower limb weakness, numbness and pain as the nerves which are often damaged supply such areas.
CES occurs more often in adults than in children. But it can occur in children who have a spinal birth defect or have had a spinal injury.
The most significant issue is that it is a surgical emergency to release the pressure on the spinal cord to prevent permanent damage. Delayed diagnosis or misdiagnosis of symptoms can mean this condition can progress to an irreversible stage. Research carried out by the Medical Protection Society (MPS) in 2016 found that failure or delay in diagnosis of CES was one of the top five errors leading to the most ‘expensive’ claims against GPs.
The study led to the MPS working with the National Institute for Health and Care Excellence (NICE) to produce revised ‘red flag’ guidelines that were published in 2018. The intention was to help healthcare professionals diagnose the condition and increase referrals for urgent investigation and medical intervention.
It is still too early to say whether the new guidance has made a significant difference to practice. However, it is hoped GPs are becoming more risk averse when providing advice to patients who may be at risk of CES, by referring them to hospital for detailed investigations.
The National Institute for Health and Care Excellence (NICE) lists the following red flag symptom and signs:
- Bilateral sciatica - occurs in both legs together. This type of sciatica is rare and may occur due to degenerative changes in the vertebrae and or the disc at several spinal levels or from Cauda equina syndrome
- Severe or progressive abnormal function of the legs, such as major motor weakness with knee extension, ankle and or foot movement
- Difficulty passing of urine and incontinence
- Loss of rectal sensation which if untreated can lead to irreversible incontinence
- Loss of feeling, tingling or numbness
- Weakness and or numbness in the anal sphincter
- A severe ruptured disk in the lumbar area (base of the spine)
- Narrowing of the spinal canal (stenosis)
- A spinal lesion or malignant tumor
- A spinal infection, inflammation, hemorrhage, or fracture
- A complication from a severe lumbar spinal injury such as a car crash, fall, gunshot, or stabbing
- A birth defect such as an abnormal connection between blood vessels
The potential long-term effects of Cauda Equina Syndrome (CES) can have a life-changing impact on patients and their families. Some patients with persistent back problems, neurological symptoms or concerns that something has gone wrong with their treatment, often do not realise that they are suffering from Cauda Equina Syndrome. It is therefore important to seek urgent medical advice if you have any of the warning signs.
If you have Cauda Equina Syndrome (CES), it is vital you receive immediate treatment to relieve pressure on the affected nerves. Surgery must be done quickly to improve recovery and prevent permanent damage, such as paralysis of the legs, loss of bladder and bowel control, sexual function, or other problems.
It is often best if this occurs within 48 hours of the onset of symptoms, but this depends on the cause of the compression and severity of the symptoms. Depending on the cause of your CES, you may also need high doses of corticosteroids which can reduce some swelling. If you are diagnosed with an infection you may need antibiotics. If a tumor is responsible, radiation or chemotherapy may be needed after surgery.
Unfortunately, there are still common themes in compensation and settlement case studies such as:
- Patients not being advised of the ‘red flag’ warning signs or presenting with worsening lower back pain radiating into their legs being dismissed as sciatica
- Failure to pay sufficient attention to a relevant medical history leading to patients not being referred for an emergency MRI scan and emergency surgery
- Delay, misdiagnosis and poor treatment in A & E departments
- Delay in hospitals performing an MRI scan of the lumbar spine, causing irreversible damage
- Following an MRI scan which demonstrates cauda equina nerve compression, an avoidable delay in transferring the patient to a hospital where the required spinal surgery could be carried out, again causing irreversible damage
- Substandard medical care - spinal operations such as a lumbar discectomy and decompression being performed in an inappropriate manner
- A haematoma (collection of blood) developing during surgery, creating pressure on the nerve roots and causing CES, even where the patient had no CES symptoms prior to surgery
Even with treatment, some patients may not retrieve full function, it depends on how much damage has occurred both given the length of time and severity of the compression. If surgery is successful, you may recover some bladder and bowel function
If negligently treated, Cauda Equina Syndrome could ultimately lead to lifelong paralysis and the need for full time support. This in turn may have consequences on mental health, relationships and cause financial hardship.
In these circumstances, the law seeks to award compensation to help you deal with any continuing problems and to maximise your potential rehabilitation and quality of life. While no sum of money can compensate the difficulties you may face, our specialist team are here to help.
We have specialist lawyers within the team including Tim Deeming who has successfully pursued cases on behalf of clients who have suffered CES and often obtained compensation of six/seven figures that will provide the help needed for the client and family's future.
We work on a no win, no fee basis, so there’s no need to worry about costs. Plus, our specialist solicitors provide an initial free assessment of your claim.
Tees is here to help
We have many specialist lawyers who are based in:
Essex: Brentwood, Chelmsford, and Saffron Walden
Hertfordshire: Bishop's Stortford and Royston
But we can help you wherever you are in England and Wales.
Chat to the Author, Tim Deeming
Partner - Medical negligence, Cambridge officeMeet Tim
- Areas of expertise
Legal 500 UK 2023
"Tim Deeming was the partner we dealt with, and he was always available to answer any questions or issues we had. He guided us through the minefield of two inquests, mediation, and always with a sensitive approach to our feelings. He was outstanding in his advice and also realistic which was very important as to the expectations of the legal process. Finally he was encouraging when we had to give evidence and was always on hand to help with statements and any evidence we needed to provide."
Legal 500 UK 2021
"Tim Deeming is supportive, friendly, knowledgeable, willing and comforting. I feel protected in his care."
Legal 500 UK 2021
"Tim Deeming has been outstanding for me. This has been a very personal, emotional and challenging event for me. I know that Tees are a business, but I’ve only ever felt like an individual; one who matters, one who deserves fair treatment."
Mr and Mrs Robin Lincoln
Tim Deeming took me through the settlement process step by step and was a master tactician in the final negotiation, who I was proud to have represent me. Katheryn Riggs gave me all the support to file the claim. Tees draw on their vast experience to bring the very best medical experts to the table.