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What is CES?
CES is a serious neurological condition whereby the nerves at the end of the spinal cord (known as the cauda equina) suddenly become severely compressed. These nerves control function of the legs, bladder and bowel. CES can lead to permanent paralysis and incontinence. There are estimated to be some 8,000 suspected cases of CES each year. An MRI scan is currently required in order to diagnose the condition.
CES is predominantly caused by disc herniation. However, it can also be caused by a tumour, infection or spinal trauma.
Symptoms of the syndrome include sciatica, weakness or numbness in both legs, numbness in the ‘saddle’ area (the parts of your body that would touch the saddle if riding a horse), difficulty passing urine or difficulty controlling bladder and bowel movements. Given the breadth of symptoms, the condition can be challenging to diagnose.
CES is a medical emergency requiring hospital admission and may involve emergency surgery to release the pressure on the nerves. The longer the condition goes untreated the greater the chance of it leading to permanent disability.
Claims for medical negligence
A recent report from Getting It Right First Time (GIRFT) - a national programme to improve medical care within the NHS by reducing unwarranted variation – reveals that more than 20 percent of all medical negligence cases involving spinal surgery in England relate to CES. One reason for this has arguably been a lack of clear specific national guidance and a variation in opinion among medical professionals about the triggers and time frames for investigation and treatment.
An earlier GIRFT report highlighted that some patients with CES are not being referred for onward care in line with protocols. According to Mike Hutton (GIRFT’s clinical lead for spinal services) the GIRFT review ‘found considerable variation in the way suspected CES was diagnosed, as well as in access to MRI out of hours and access to emergency operating lists’.
Postcode lottery
A 2021 investigation by the Healthcare Safety Investigation Branch (HSIB) - an organisation dedicated to improving NHS patient safety - found problems in obtaining MRI scans and also reported a variation in time frames, with the terms ‘urgent scan’ and ‘emergency scan’ used interchangeably with different meanings in different locations, causing ‘confusion’.
Further, in one case they discovered problems with the onward referral process to specialist spinal centres. According to HSIB, the treatment pathway for CES all depends upon which hospital undertakes the initial assessment and within which ‘spinal network’ the local hospital sits geographically.
New guidance
GIRFT has now published the National Suspected Cauda Equina Pathway which Mike Hutton considers, once implemented, will reduce patient harm.
One aspect of the pathway sets out that a patient presenting to their GP (or in another community care setting) with CES type symptoms that started within the last two weeks, should be referred as an emergency to the nearest hospital that can perform an urgent MRI scan.
The relevant hospital should then carry out a bladder scan and emergency MRI as soon as possible and certainly within four hours of this being requested. Guidance is also provided where surgery is required including specific provision for catheterisation prior to surgery and bladder scans post-surgery. Claims for clinical negligence can arise where there are failures in the assessment of bladder function and urine retention leads to bladder damage.
Guidance published simultaneously by The Clinical Imaging Board (CIB) includes a provision that all acute services should have 24/7 MRI availability on-site by June 2024.
This new guidance represents real progress for the protection of patients and for those involved in bringing claims for medical negligence. It should provide clarity in terms of the steps that ought to have been taken by the medical professionals in any particular case. Hopefully, improvements in service will be seen quickly. However, given the current staffing shortages faced by the NHS and with reported fears of a 44 percent shortfall in consultant radiologists by 2025, it remains to be seen how the new guidelines will be followed in practice.
How Kingsley Napley can help if you have suffered poor treatment for CES
We are specialists in bringing claims relating to CES and our solicitors have dealt with many cases relating to delays in diagnosis and treatment of the condition including failures to undertake a timely MRI scan or surgery. We understand the difficulties for our client’s living with permanent repercussions of CES and seek to obtain the maximum awards of compensation to address all of their future needs and, where possible, to obtain early funds to deal with immediate rehabilitation.
If you would like to speak to a member of our medical negligence team then please call us on 020 7814 1200.
about the author
Richard Lodge is a Partner in the Medical Negligence and Personal Injury practice and has been recognised within the field of clinical/medical negligence within the Chambers UK and Legal 500 directories. He is an individually ranked lawyer for clinical negligence within Chambers UK, A Client’s Guide to the UK Legal Profession.
We welcome views and opinions about the issues raised in this blog. Should you require specific advice in relation to personal circumstances, please use the form on the contact page.
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