Rare spinal condition costing NHS millions in compensation

Cauda equina syndrome (CES) is a relatively unknown spinal condition that - according to a recent article in the BBC - the NHS is repeatedly failing to diagnose and treat in sufficient time, leading to hundreds of millions of pounds in compensation claims.

What is cauda equina syndrome?

The cauda equina is a bundle of nerves that branches off from the bottom of the spinal cord. Cauda equina syndrome is a rare spinal condition that occurs when those nerves become damaged.

The most common cause is disc herniation (a ‘slipped disc’) in the lower back; other causes include trauma, surgery, spinal stenosis, inflammatory conditions and tumours.

The condition can have significant long-term consequences for those affected if it is not diagnosed and treated promptly. After 24 hours, the damage to the cauda equina is such that outcomes for patients become significantly worse, which is why immediate treatment is pivotal.

How is CES diagnosed and treated?

CES may be suspected from the patient’s symptoms, but diagnosis will need to be confirmed by a scan - usually an MRI scan.

Sudden-onset CES is a medical emergency requiring urgent surgery, usually in the form of surgical decompression to relieve the pressure on the cauda equina nerves.

The success of the treatment depends on the severity and duration of the compression. More information on CES can be found here.

Warning from Royal College of GPs

Now, the Royal College of GPs is warning that although the condition is rare, the effects of CES are so serious that all doctors should be keeping an eye out for signs among patients.

Symptoms of the condition include numbness between the legs (‘saddle anaesthesia’); problems with bowel and bladder function; sexual problems; back pain and pain, numbness or weakness in both legs. These are known as ‘red flag symptoms’, which require urgent investigation.

However, common symptoms lower back pain and leg pain are often signs of less serious back problems which can lead to delayed or even the misdiagnosis of CES.

"Ideally you want to catch this condition in a matter of hours, do an MRI scan and do decompressive surgery," says John Reynard, a consultant urological surgeon at Oxford University Hospitals NHS Trust.

There is also a general belief that a lack of resources, as well as a lack of awareness among medical professionals, is making the current situation worse.

"CES requires a clinical and radiological diagnosis, so it is critical that patients get an MRI scan, which is the only way to confirm the condition," says Nisaharan Srikandarajah, a trainee neurosurgeon with a PhD in cauda equina syndrome.

"Sadly there is a shortage of MRI radiographers working out of hours, which causes delays in getting the critical diagnosis."

“I didn't know there was a ticking clock above my head”

One woman suffering with cauda equina syndrome is Catrina Farnell, of Skipton, Yorkshire. Catrina was 23 and a talented dancer with dreams of becoming a choreographer, when she contracted the condition. She was in London at a sporting event, when she bent to pick up a bag. Catrina told her story to BBC News:

"Something happened to my back… It was excruciatingly painful. I didn't know what to do. I'd never even heard of cauda equina syndrome, so I didn't know there was a ticking clock above my head. I woke up a couple of hours later unable to move my legs, with numbness and pins and needles, and eventually unable to urinate."

Now 31, Catrina is dependent on crutches and a wheelchair as her legs, bowel, bladder and sexual organs are all severely damaged, and her elderly mother Margaret, 74, has become her carer. Catrina added:

"I want to have children and I want to meet someone to be with but it feels now that they'd be more of a carer, you know because being with me, people instinctively take on the role of looking after me.

"So, it just completely took that element of my life away."

£68m in CES compensation settlements

Assessing the number of people with the condition is problematic as some hospitals do not log case numbers. The last figures available are for the year between 2010-2011 and show that 981 surgical decompressions took place in England alone during this time.

The NHS approximates the cost of CES compensation claims between 2014-16 was around £68 million. A staggering two thirds of this figure relates to claims for delay or failure of diagnosis and/or treatment. However, it must be noted that this does not include claims against GPs so the actual figure could be much higher. John Reynard added:

"It's difficult to get a precise figure from all the various information sources about the frequency of delays in diagnosis of cauda equina syndrome.

"I would estimate that it is something in the order of £150m to £200m a year in terms of compensation payments, covering legal costs."

Compensation settlements can reach £4m per CES claim, and this is excluding legal fees.

The settlement amounts are so high partly because a large number of individuals who contract cauda equina syndrome are young, may not be able to work again and will require care for the rest of their lives.

Comparing the condition to meningitis, chairwoman of the Royal College of GPs, Prof Helen Stokes-Lampard, said:

"Cauda equina syndrome is a rare condition but, like meningitis, one that every doctor will be on alert for because of how serious it can be if not detected and managed swiftly.

"The vast majority of acute back pain and back problems will not be serious and can be safely managed through careful exercises or over-the-counter painkillers, but if a patient experiences any of the red-flag symptoms for cauda equina syndrome, they should seek medical attention as soon as they can."

NHS Resolution, formerly the NHS Litigation Authority, said it was "committed to sharing information with our NHS trust members to highlight some of the red flags related to cauda equina syndrome".

"We are working closely with trusts and the wider NHS system to reduce avoidable harm to patients," it said.

Helen Budge, a Senior Solicitor within the Clinical Negligence department here at Potter Rees Dolan, comments:

Sadly, we see many cases where the diagnosis of cauda equina syndrome has been delayed and the long term outcome is worse than it would have been with earlier surgery.

In our experience, there is reasonably strong awareness amongst medical professionals of the more specific signs of CES such as saddle anaesthesia or bowel or bladder dysfunction. However patients with early CES who present with back and leg problems are much less likely to have an urgent MRI scan which would allow intervention before they start to deteriorate.

Read how our expert Clinical Negligence team secured over £2 million for a woman who was left paralysed after a misdiagnosis

Helen Budge is a senior clinical negligence solicitor with Potter Rees Dolan. Should you have any queries about cauda equina syndrome, spinal cord injuries or any other clinical negligence issues and wish to speak with Helen or any other member of the team, please contact us on 0161 237 5888. Alternatively, you can contact Helen directly here.