Cauda Equina Syndrome - ‘red flag’ symptoms updated by NICE to aid earlier referral

Posted: 15/05/2018

Cauda Equina Syndrome occurs when the nerves of the Cauda Equina, which supply the bladder, bowel, lower limbs and even the sensation to the skin around the buttocks and the back passage, become compressed. It is a medical emergency because failure to release compression in a timely manner can result in irreversible damage as root cells cannot regenerate.

If Cauda Equina Syndrome is suspected, an urgent MRI is required to confirm the diagnosis and, once confirmed, urgent surgery should be carried out. If surgery is not performed in a timely manner, patients can suffer from the following long-term side effects:

• loss of bladder function and bladder control
• loss of bowel function and faecal incontinence
• loss of sexual function
• loss of sensation in the perineum (the area between the anus and the scrotum/vulva), genitalia and buttocks
• loss of leg function
• chronic lower back, leg and buttock pain

As the consequences of a delay in diagnosis are so huge, this often results in medical negligence claims. The Medical Protection Society (MPS) reported in 2016 that one of the top five errors resulting in the most expensive GP claims was a failure to diagnose / delay in diagnosing Cauda Equina Syndrome.

The National Institute for Health and Care Excellence (NICE) has therefore recently revised the ‘red flag’ symptoms included in the NICE Clinical Knowledge Summaries in order to help GPs and other healthcare professionals spot the warning signs and ensure patients are referred to hospital as early as possible.

The new ‘red flag’ symptoms are:

• bilateral sciatica (pain in the lower back on both sides which radiates down the back of the legs)
• severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
• difficulty initiating micturition (urination) or impaired sensation of urinary flow
• loss of sensation of rectal fullness
• perianal (anus), perineal (area between the anus and scrotum or vulva) or genital sensory loss such as saddle anaesthesia or paraesthesia
• laxity of the anal sphincter (anal incontinence) 

Emily Hartland, an associate in the clinical negligence team at Penningtons Manches, says: “We act for a number of clients who have visited their GP and described red flag symptoms consistent with Cauda Equina Syndrome - including urinary issues, saddle numbness and lower back and leg pain. Despite this, Cauda Equina Syndrome was not considered and the patients were sent home rather than referred to hospital for an urgent MRI scan. Cauda Equina Syndrome is relatively rare meaning some GPs will not have come across the condition in clinical practice before. Hopefully the new red flag symptoms will help them become more familiar with the condition and the fact that it is a medical emergency requiring immediate attendance at hospital for further investigation.”

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