Popular search terms
Click each term for related articles
Healthcare
Cauda equina syndrome (CES) is relatively rare but nevertheless gives rise to a number of clinical negligence claims.
The condition occurs when a lumbar disc prolapse presses on the central nerves which control bladder, bowel and sexual function and sensation to the buttock and genital area. Initially, a person may develop impaired sensation in the perineal and saddle area as well as some bladder and bowel dysfunction (incomplete CES or CESI). This is generally before permanent neurological damage has occurred and therefore hopefully reversible. Ultimately, a person can lose all bladder and bowel control (retentive / complete CES or CESR). This is generally irreversible as permanent damage has occurred. The time it takes to progress from CESI to CESR is extremely variable. Clearly, the key to successful treatment is identifying the condition as early as possible and undertaking surgery before any permanent damage has been done.
There has long been considerable debate in the medical world (and by extension the medicolegal world) as to the importance of the timing of surgery. There is a broad (although not complete) consensus that, once a patient reaches CESR, the timing of surgery is unlikely to make much difference to the outcome. However, in relation to the timing of treatment with patients presenting with CESI, the position has been more hotly debated.
Some have argued that there are windows of opportunity from onset of symptoms – within 24 hours, within 48 hours, after 48 hours, and that outcomes will vary depending upon the timeframe within which the decompression surgery is performed. Others have argued that the timing is not the crucial issue but rather the extent of the symptoms immediately prior to the surgery and that this is the best predictor of outcomes after surgery.
As you can imagine, these two arguments in the medical literature have been replicated in expert evidence in cauda equina claims relating to delay in undertaking surgery, with Claimants arguing a worse outcome if surgery was not performed within crucial 24 or 48 hour timeframes.
However, in January 2023, new research was published based on the largest prospective study of patients with CES ever undertaken (Woodfield et al). This arguably eclipses all other studies due to its size (over 600 patients) and extent (assessment of presentation, investigation, management and outcomes up to one year post operatively using both clinician and participant reporting). The findings are supportive of the view that the key determinant of outcome is not timing of surgery from onset of symptoms but the status of the patient’s symptoms at the time of surgery.
Of course, timing is important insofar as surgery clearly prevents further deterioration but the fixed timeframes advocated by some and argued by Claimants for years have arguably been fatally undermined.
Clyde has a large and growing healthcare team around the country working on behalf of NHS Trusts, GPs and private healthcare providers. The team has extensive experience in this area of clinical negligence.
End