Psychological effects following a diagnosis of Cauda Equina Syndrome: the importance of mental health in treatment and litigation

Posted: 19/10/2020

Cauda Equina Syndrome is a potentially devastating condition, caused by the compression, usually by a herniated spinal disc, of the nerves at the base of the spinal cord. It is a recognised emergency and surgical decompression is normally required within 24 hours of onset in order to minimise the long-term effects.

Whilst rare in itself, the physical consequences of Cauda Equina Syndrome are well understood - particularly if the problem is not treated rapidly, as the condition can result in ongoing neurological pain, permanent loss of sensation and power in the lower limbs, urinary or faecal incontinence and loss of sexual sensation and function. The longer the delay in treatment, the worse these effects tend to be.

Some of the physical effects can be severe and lifelong, but may also be treated or managed with physiotherapy, drugs or surgery.

It is not surprising therefore that many patients suffer psychological issues as well as physical effects following the development of Cauda Equina Syndrome. The syndrome can affect people of all ages, and the loss of mobility, independence, continence or sexual function can be emotionally debilitating.

Any treatment for Cauda Equina Syndrome should therefore include consideration of these psychological side-effects. The spectrum of potential disorders is a wide one - some patients may develop no psychological symptoms at all while others may develop symptoms ranging from a relatively mild adjustment disorder to a severe and debilitating depression. Where a patient falls in that range may depend on the severity of the disease, the impact on their work, social or domestic life and the inherent resilience of the individual. The different types of mental disorders are classified in Chapter V of the tenth International Classification of Diseases (ICD-10), published by the WHO.

An adjustment disorder is a group of symptoms, including stress, sadness, or a feeling of hopelessness, which can accompany a significant life event. It can also present with additional physical symptoms such as trembling, twitching or fatigue. The onset of the disorder is usually within a month of the event, and the condition does not usually persist beyond six months. If symptoms exceed this period, the diagnosis is usually adjusted: for instance, to a prolonged depressive reaction. This is usually a relatively mild depressive state, but may last for up to two years.

Some patients may suffer a post traumatic stress disorder, which can be a delayed or protracted response to a stressful event or situation which is of an exceptionally threatening or catastrophic nature. Often associated with combat stress, the disorder is recognised in Cauda Equina Syndrome patients and can include flashbacks to the events surrounding diagnosis, leading to fear and avoidance of cues that remind the sufferer of the original trauma. These avoidance tactics may result in alcohol or substance abuse.

Depression is well recognised and there are defined criteria for diagnosis, assessed from a list of symptoms including persistent low mood, loss of interest or pleasure, fatigue or low energy, disturbed sleep, poor concentration, agitation, and suicidal thoughts or psychotic symptoms. The more of these symptoms a patient has, the more severe the diagnosis of depression will be.

Fortunately, many of these problems can be successfully treated with good results. A treatment regime will need to be tailored to the individual and its efficacy will depend on the classification of the patient’s particular problem, along with consideration of their psychological make-up and social and support networks in addition to the concurrent treatment of their physical symptoms.

Treatment may involve counselling, cognitive behavioural therapy, sexual counselling or couples therapy and antipsychotic or antidepressant medication, as well as treatment for any associated addictions such as alcohol or drugs.

The litigation process in itself can be stressful, and feelings of anger and dismay arising from delayed treatment can contribute to the mental challenges that patients may face. It is recognised that some patients may not make significant progress in their psychological state until a claim is settled. This is again something to be assessed by the treating psychiatrist. However, some patients find the settlement of a claim, along with an apology or recognition from the defendant, to be cathartic. A key advantage to bringing a claim is that the patient will have access to an expert psychiatrist who will recommend a tailored regime of treatment. If a claim is successful, the costs of expert treatment will be borne by the defendant.

Philippa Luscombe, a partner in the specialist Cauda Equina Syndrome subteam at Penningtons Manches Cooper, said: “The importance of mental health has gained increasing recognition in recent years, and it is essential that the psychological effects of Cauda Equina Syndrome are recognised and treated with the same rigor as the physical effects. Patients are unlikely to recover spontaneously and may face a lifelong vulnerability to psychological problems. With a proper long-term treatment plan in place, the likelihood of severe or ongoing symptoms can be significantly reduced. We are fortunate to work with a number of expert psychiatrists with experience of the condition who are well placed to suggest effective treatment plans for our clients.”

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