Cauda equina syndrome (CES) is a rare neurological condition and spinal emergency that can be easily missed by medical professionals, where a late or misdiagnosis can result in a patient suffering from permanent damage. Still, the fact that CES is rare does not necessarily excuse any failure to diagnose or urgently treat this condition, especially where the red flags were there to be spotted.

The following guide to CES examines the various cauda equina red flags with a view to pursuing a medical negligence claim against the NHS where a patient has presented to their GP or at hospital exhibiting CES symptoms.

What is cauda equina syndrome (CES)?

The cauda equina is a group of nerves at the bottom of the spine, reaching across the lower back and hip region. ‘Cauda equina’ is Latin for ‘horses’s tail’ because of its shape.

Cauda equina syndrome (CES) is a disorder caused by compression of these nerves.

CES is essentially a rare spinal condition characterised by persistent severe low back pain, where a diagnosis of cauda equina compression will usually require emergency surgical intervention, typically within 24 hours. If not diagnosed and treated promptly, this condition can lead to permanent paralysis of the legs, irreversible bladder and/or bowel control, loss of sexual sensation and a range of other debilitating problems.

What are the cauda equina syndrome red flags?

Cauda equina syndrome red flags refer to those symptoms which should alert any reputable and responsible medical practitioner to the possibility that the patient has already developed or is at risk of developing CES and that immediate action may be needed. As such, cauda equina red flags refer to the potentially serious spinal pathology which must be treated as a matter of urgency, where emergency surgical intervention may be needed.

The red flag symptoms of CES include:

  • severe low back pain, with or without pain into the lower limbs
  • pain and altered sensation in the legs, known as bilateral sciatica
  • motor weakness and loss of reflex(es) in the lower limbs and ankles
  • changes in bladder function, such as straining or an impaired sensation of urinary flow
  • changes in bowel function, such as loss of sensation of rectal fullness, laxity of the anal sphincter, rectal incontinence and faecal retention
  • tingling or loss of sensation between the legs and saddle area, known as the perineum
  • alteration of sexual sensation, genital sensory loss or erectile dysfunction.

Red flags are extremely important as early recognition can lead to correct timely diagnosis and treatment. Unfortunately, some of these symptoms can also be caused by other more common back problems, including sciatica — this is where the sciatic nerve, which runs from the lower back to the feet, is irritated or compressed — as such, a diagnosis of CES may be missed, significantly increasing the chances of irreversible neurological damage.

What are the causes of cauda equina syndrome?

Cauda equina syndrome is a rare but well-recognised neurological and emergency condition typically caused by degenerative changes in the spine that result in compression of the cauda equina. These are the multiple nerves located at the bottom of the spinal cord which send and receive messages both to and from the lower limbs and pelvic organs.

In between each vertebra or the back bones of the spine is an intervertebral disc. These discs prevent the vertebrae from rubbing together and help to absorb shock. However, intervertebral discs can often become worn with age, creating degenerative changes in the back. In turn, degenerative discs have an increased propensity to slip or herniate, where this is especially prevalent in the lower back or lumbar region. Around 2% of patients with a herniated lumbar disc will go on to develop cauda equina syndrome as a result of this happening, typically when a large central disc prolapse in the lowest two discs of the spine presses upon the cauda equina causing severe pain and other related problems.

However, in addition to ruptured discs in the lower back, compression of the cauda equina may also be caused by spinal injury and trauma, an infection or the presence of a tumour.

How should symptoms of CES be treated?

Most patients with a herniated lumbar disc will experience back pain, although CES can also lead to symptoms such as urinary incontinence, faecal leakage, reduced sensation or numbness in the saddle region and erectile dysfunction. This is because within the cauda equina are nerves that control the bladder, bowel and genital sensation.

As the body has its own capacity for healing, and in conjunction with physiotherapy and anti-inflammatory medication, the pain and symptoms caused by most herniated lumbar discs will subside without the need for surgery. However, on occasions, this pain can persist for several months, where a patient may be advised that an operation is needed to remove part of the disc to take pressure off the nerve. In contrast, if the symptoms of CES are to be cured, urgent decompression surgery must be carried out. As such, where the disc is pressing upon the cauda equina, medical practitioners cannot wait to see what happens, as would be the case with a normal herniated disc. They must instead order urgent surgery.

For GP’s dealing with patients exhibiting symptoms of cauda equina syndrome, the patient should be advised to immediately present themselves to the accident and emergency department of their local hospital. If a patient attends A&E with these symptoms, this should merit an immediate referral for an MRI scan by any triage or treating physician. This is because the patient may be in imminent danger of developing complete CES and will therefore need confirmation of the cause of their symptoms as a matter of emergency.

Once a patient has lost the sensation in the bladder and is no longer aware of the need to urinate, characterised by painless urinary retention and overflow incontinence, they will be classed as having complete CES, at which stage surgery may be less effective. However, even in these cases, an urgent MRI scan should still be undertaken to confirm a diagnosis and to determine what action can be taken to help alleviate any other symptoms.

What can you do if cauda equina red flags are missed?

If you have been let down by medical professionals, where cauda equina syndrome has gone untreated resulting in ongoing or irreversible symptoms, you may have a medical negligence claim as the result of a late or misdiagnosis made by an NHS practitioner.

Medical negligence, also commonly referred to as clinical negligence, is a term used to define an incident where a medical professional — such as a GP, triage nurse or consultant specialist — has breached the duty of care obligation to you as a patient. In some cases this may be down to ignorance, carelessness or even exhaustion due to being overworked. The cause for any wrongdoing is not important, provided there has been some want of care.

As such, if you presented to your GP or at A&E exhibiting cauda equina red flags that were missed by a medical practitioner, and you did not receive the emergency surgery that you needed, either at all or in time, you may have a valid claim for compensation. Essentially, if medical errors caused you to suffer permanent neurological damage, you should seek immediate legal advice from a solicitor specialising in CES claims.

Your solicitor will be able to negotiate on your behalf with NHS Resolution, the arm’s length body responsible for dealing with NHS litigation. If an out-of-court settlement cannot be reached, they will also be able to prepare and conduct the litigation needed to pursue a compensation claim before the courts. Importantly, most personal injury claims must usually be issued within a period of 3 years of the alleged wrongdoing taking place, or within 3 years of becoming aware that something went wrong, so instructing a solicitor at the earliest possible opportunity will help to ensure that your claim is not time-barred.

How do you prove that cauda equina red flags were missed?

To prove a claim for medical negligence you will need to be able to show, on a balance of probabilities, that an NHS practitioner breached their duty of care towards you and, because of this breach, they caused you harm that you would not otherwise have suffered. This means being able to show that you suffered symptoms that could have been avoided if you had received a timely diagnosis and treatment. This also means being able to show that the treatment received fell below the standard of a responsible body of medical opinion.

As such, your solicitor will need to obtain expert opinion to consider the cauda equina red flags that you were exhibiting when you presented to your GP or at A&E, where that expert must conclude that by failing to provide a timely CES diagnosis and treatment, your level of care fell short of the standard of care considered reasonable in that field of expertise.

All medical negligence claims, including cauda equina claims, can be complex. They require expert opinion, together with a clear account of the history of symptoms that you described to doctors, and the timing involved between reporting the matter and the alleged breach. However, with the help of a specialist solicitor, it is possible to recover compensation for the injury and loss that you have suffered as a result of the substandard level of care received.

Equally, you may have a claim in medical negligence if you presented to your GP with symptoms to suggest that you may be at risk of developing CES, but your GP failed to warn you of the importance of seeking urgent medical attention should any cauda equina red flag symptoms develop. This is because any failure by a GP to advise a patient in these circumstances may also be found to be negligent if that patient subsequently deteriorates to the point where any surgery would be less effective because they didn’t attend A&E.

Early symptoms which might suggest that a patient is at risk of developing CES could include pain from the lower back spreading into both legs, altered sensation or tingling in the lower limbs, weakness in the legs and reflexes, altered bladder and/or bowel function, as well as general numbness in the saddle area and the start of genital sensory loss.

What compensation could you get for a cauda equina claim?

Delays to the assessment, scan and treatment of cauda equina syndrome can lead to life-changing injuries. These can include mobility issues, bladder and bowel incontinence, sexual dysfunction, as well as chronic pain and fatigue, all of which can have a severe impact on your quality of life. These types of problems can also effect your family’s life.

Even though an award of compensation cannot make up for the debilitating effects of a cauda equina misdiagnosis, resulting in irreversible problems, it can help you to get some justice for what has happened and to provide the financial support to move forward.

The amount of compensation for medical negligence claims can vary from case to case, where the value of any award will depend on the nature and severity of the symptoms suffered because of the alleged wrongdoing, as well as the impact of this on the patient’s life. Although compensation will not be awarded for any pain or symptoms suffered prior to the alleged breach of care, you can potentially claim for all of the consequences that follow as a result of you not receiving emergency surgery for cauda equina compression, although there may potentially be causation issues over what permanent symptoms would have been likely, even if surgical intervention had been immediate. This is because cauda equina syndrome can sometimes cause permanent debilitating effects, despite urgent treatment.

Still, any compensation claim for misdiagnosed cauda equina will typically comprise a sizeable claim for general damages, to reflect the pain, suffering and loss of amenity caused, together with special damages to reflect the financial losses flowing from any permanent disability. This could include a claim for past and future loss of earnings, the cost of any subsequent medical care or treatment, as well as the cost of any medication. A compensation claim for this type of injury can never really put you back in the position that you would have been in had the accident not happened, but it can help to make life easier for you and your family as you adjust to living with the long-term effects of your condition.

Cauda equina red flag FAQs

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Legal disclaimer

The matters contained in this article are intended to be for general information purposes only. This article does not constitute legal advice, nor is it a complete or authoritative statement of the law, and should not be treated as such. Whilst every effort is made to ensure that the information is correct, no warranty, express or implied, is given as to its accuracy and no liability is accepted for any error or omission. Before acting on any of the information contained herein, expert legal advice should be sought.


Gill Laing is a qualified Legal Researcher & Analyst with niche specialisms in Law, Tax, Human Resources, Immigration & Employment Law.

Gill is a Multiple Business Owner and the Managing Director of Prof Services - a Marketing Agency for the Professional Services Sector.

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