Cauda Equina Syndrome is a serious neurological condition of the spinal cord which should be treated as a surgical emergency. Most, although not all, cases are due to a slipped disc. Many people have degeneration in their spine and degenerate discs can prolapse through wear and tear or trauma resulting in compression of the bundle of nerves at the base of the spine known as the Cauda Equina or ‘horse’s tail’. Prolonged compression of these nerves, which control lower limb sensation and sexual, bladder and bowel function, can cause permanent damage – which is why urgent surgery to remove the compression from the disc is required. While early diagnosis and surgery often mean a complete recovery, delayed surgery can result in life-changing disabilities.
Many patients with this condition have a history of back pain and sometimes sciatic pain in their legs. Signs that should raise suspicion of Cauda Equina Syndrome include:
When any patient presents with back pain and some or all of the other signs above, Cauda Equina Syndrome should be suspected. Diagnosis is confirmed by thorough examination, including testing of power and sensation, and where there are clinical signs of Cauda Equina Syndrome, MRI imaging is used to verify the diagnosis. If Cauda Equina Syndrome is diagnosed clinically and on imaging, then in most cases arrangements should be made to perform surgery as a matter of urgency. Often hospitals do not have resident neurosurgical teams and so arrangements need to be made for the patient to be transferred to such a team for surgery.
All primary care practitioners (GPs, A&E and out of hours services) and all orthopaedic and neurosurgical teams should be aware of Cauda Equina Syndrome, its usual clinical signs (known as ‘red flag symptoms’) and the fact that in the early stages the condition is a surgical emergency. There is much debate about what the ‘window of opportunity’ for a good outcome is but it is generally accepted that:
In order to succeed in a claim for delayed diagnosis, patients will need to prove negligence ie that one or more of the medical staff providing care did so in a way that would not be supported by any responsible body of practitioners. In this context the issues are usually:
To succeed in a case, both negligence and causation need to be established, ie that the alleged negligence has caused damage. This is often the more difficult and contentious part of a Cauda Equina Syndrome claim. Patients who present early after the onset of Cauda Equina Syndrome and then receive inadequate care can usually show a progression of their symptoms over the period of negligent delay and establish that earlier surgery would have produced a better outcome, or even full recovery. Those who present later, have a very swift progression or whose symptoms do not progress at all during the period of delay may find it more difficult to show that the delay has caused damage.
Proving clinical negligence is conditional on independent medical expert evidence addressing the standard of care provided and the effect of any failures. Experts will assess the case based primarily on medical records and imaging (MRI) but the patient’s evidence on when symptoms developed, how they progressed and what happened when they were assessed will also be key. We therefore obtain a full set of medical records from the patient’s GP and hospital as well as evidence from the individual concerned, consider if we think there is a claim to be pursued and ask our experts to give their opinion. If they are supportive of a claim, we pursue it from there.
Clinical negligence cases do take time, partly since both sides are dependent on medical experts who are usually busy juggling their clinical practice and expert witness work and partly as a result of the complexity of the issues involved. Cauda Equina Syndrome claims are particularly complicated because evidence is crucial and because of disputes over timing of surgery and outcome. For those left seriously disabled, we cannot value and settle the claim until we know the likely long term prognosis and what needs they will have as a result. We will progress everything as quickly as we can but cases could take two to three years until they are concluded. However, if liability (negligence) is admitted relatively early, it is sometimes possible to obtain an early payment of some damages (interim payment) to fund treatment / support needs while the case is ongoing.
From the date of the negligence, patients have three years to bring a claim – it must be settled or court proceedings issued by that three year deadline or patients are ‘time barred’. This is known as the ‘limitation period’. Sometimes the period starts to run a little later than the actual date of negligence where patients were not and could not have been aware of any negligence or injury, but in most Cauda Equina cases the date of negligence is the usual start point. In cases where the patient is below the age of 18, the three-year time limit begins from the date of their 18th birthday and for any patients lacking capacity to litigate (due to mental impairment rather than physical), the time limit does not apply.
While there is therefore no immediate urgency to bring a claim, we advise patients in Cauda Equina cases that the earlier they look into a claim the better as their recollection of events is often crucial. The sooner the process starts, the sooner all that detail can be taken and recorded in a witness statement.
We always advise people to think carefully before bringing a claim – as it takes time and by definition involves a focus on the negative as patients go over the events in question. However, for those who have a poor outcome as a result of a delayed diagnosis of Cauda Equina Syndome, the difference that bringing a successful claim makes to their life can be significant. Examples of the areas where we can claim and recover damages are:
If you or a family member have suffered from Cauda Equina Syndrome and feel that your care was not appropriate, we are happy to talk to you or visit you, in the first instance on a no charge and no obligation basis, to go through what happened and advise you on whether you have grounds for a clinical negligence claim. Please call us on 0800 328 9545, email us on firstname.lastname@example.org or contact a member of the Cauda Equina team directly.