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Your guide to cauda equina syndrome

Woman holding lower back in pain

Cauda Equina Syndrome (also known as CES) is a relatively rare but serious condition caused by extreme pressure to the nerves at the lower end of the spinal cord. A GP, doctor or hospital consultant should recognise a patient’s 'red flag’ symptoms, which should trigger emergency medical attention.

Damage to the spinal cord itself is almost always irreversible. Recovery depends on the accuracy of the diagnosis and the subsequent promptness of treatment and care by doctors, specialists and other practitioners on a medical team.

Life-changing consequences

If diagnosis, testing and treatment are not received within 8 hours, the outcome for a patient can be life-changing.

Long term consequences include:

  • Difficulty in walking
  • Impaired bladder and/or bowel control
  • Nerve/neurological problems
  • Permanent paralysis

A permanent spinal injury can have a devastating, traumatic impact upon the whole family, especially if the damage was avoidable and if sufficient care was not taken.

Permanent damage and spinal injuries caused by complications arising from symptoms missed, misdiagnosed or mistreated can all be grounds for clinical negligence claims relating to cauda equina syndrome.

As these cases are often complicated, it is vitally important that you seek a legal expert who has a specialist knowledge of the key medical issues, together with a sympathetic and sensitive understanding of how everyone involved is affected.

Your Legal Friend has many years of experience in successfully resolving different types of clinical negligence cases.

We can help you:

  • Find out the reason why you or a member of your family werenot given the duty of care you were owed, and crucially
  • Secure appropriate compensation to ensure that the cost of providing the necessary special care, support, treatment and equipment will be properly met, both now and in the future.

 How common is Cauda Equina Syndrome?

  • Cauda Equina Syndrome occurs in around 2% of cases of herniated lumbar discs (“slipped disc”).
  • Around a third of UK adults have lower back pain.               (NHS UK, 2014)
  • 40,000 people in the UK are estimated to be living with a spinal cord injury(BackUp Trust)
  • Around 500–600 people suffer from acute traumatic injuries to the spinal cord each year in the UK.
  • Just 7% of spinal injury cases are referred within 24 hours.
  • 59% of spinal injury cases are admitted to hospital within 30 days.           (Spinal Injury Assessment Guide - NICE 2013/15)

What exactly is Cauda Equina Syndrome? 

Where the spinal cord ends between the first and second lumbar vertebrae of the lower back, the spinal nerves branch out individually in a formation resembling a "horse’s tail", otherwise known by the Latin term, cauda equina. 

Nerves in the cauda equina help to control and manage many lower parts of the body including, the bowel, bladder, legs and sexual function. Injury resulting in paralysis to these nerve roots is referred to as Cauda Equina Syndrome. 

What causes Cauda Equina Syndrome?

Cauda Equina Syndrome is caused by pressure on the spinal nerves due to one of the following:

  • A herniated (“slipped”) disc
  • Lumbar spinal stenosis - narrowing of spaces in the spine
  • Spinal tumours or neoplasms (tissue growths)
  • Inflammatory conditions of the spine
  • Infections in the spinal canal, such as a spinal epidural abscess
  • An injury that penetrates the lower back
  • Trauma to the lumbar spine, such as a car accident or a fall
  • Medical treatment, such as surgical errors. 

Common Symptoms

This depends on which nerves are affected and the degree of nerve compression and subsequent irritation.

Common symptoms can include:

  • Pain in the lower back
  • Loss of feeling / progressive weakness or numbness in the legs and/or feet, including difficulty walking
  • Sharp stabbing pain in one or both legs radiating down from the buttocks
  • Urinary or bowel incontinence and/or loss of rectal control
  • Sexual dysfunction.

Onset of symptoms - can occur suddenly or develop over weeks or years:

  • Sudden onset - bladder and/or bowel incontinence or dysfunction and/or progressive weakness in the legs and/or feet.
  • Gradual onset - include recurring back pain together with muscle weakness and numbness and bladder and/or bowel incontinence or dysfunction.

Two different classifications – the syndrome can be classified as

  • Incomplete CES (CESI) and
  • Complete CES (or CES with true retention - CESR).
  • Incomplete Cauda Equina Syndrome - CESI

Patients are diagnosed with motor and sensory changes, including loss of feeling but have yet to develop full retention or incontinence of either bowel or bladder.

  • Complete Cauda Equina With True Retention - CESR

Patients experience painless urinary and bowel retention and, eventually, overflow i     incontinence. 

‘Red Flag’ symptoms

These are crucial signs that a GP, hospital doctor or medical team member should recognise and immediately act upon without delay to confirm diagnosis and provide urgent medical treatment. 

‘Red flags’ that point to Cauda Equina Syndrome include:

  • Complete numbness/loss of feeling in buttocks, perineum and inner surfaces of the thighs, known as the ‘saddle area’
  • Paraesthesia - an unusual or unexplained tingling, pricking, or burning sensation in the ‘saddle area’
  • Recent onset of bladder dysfunction
  • Recent onset of faecal incontinence or unexpected relaxation of the anal sphincter
  • Severe or progressive nerve function in the lower limbs. 


Diagnosing Cauda Equina Syndrome (CES) can be a challenge - not only is the condition rare but the symptoms are also closely linked to other similar conditions. However it is vital that Cauda Equina Syndrome is diagnosed in the early stages, while the condition is still incomplete.

A common complaint is lower back pain with leg pain and/or weakness.  Early diagnosis and treatment are essential toincrease the chances of a successful recovery and prevent the risk of permanent nerve damage, bladder and/or bowel dysfunction.

To confirm a diagnosis of Cauda Equina syndrome, the following actions should take place:

  • Examination of patient’s full medical history - to determine any previous damage to the spine that could cause further complications.
  • Physical examination - to include:
      • Testing the muscle strength of the lower limbs
      • Evaluating sensation to touch and pain
      • Checking lower limb reflexes
      • Assessment  of anal tone, reflex and sensation
      • MRI/CT scan - to provide a detailed look at tumours, infection, intervertebral discs, and nerve roots.
      • X-ray scan - to look for severe arthritis and trauma.
      • Myelogram – a coloured dye is injected into the spinal canal to show any pressure on the nerves or spinal cord.


Within 8 hours of onset of symptoms – this is the recommended time limit for emergency surgical decompression to reduce or eliminate pressure on the nerve. 

Within 24 to 48 hours - surgery should be performedto provide the maximum potential for improving sensory and motor response as well as bladder and bowel functioning.

If more than 48 hours is allowed to elapse - after compression of the cauda equina nerve, the damage to the nerves will be extensive. A patient could be left with long-term complications, such as paralysis, loss of bladder control and/or loss of bowel function.

Cauda Equina Syndrome – A Case Of Clinical Negligence?

Failure to recognise symptoms

Cauda Equina Syndrome (CES) can develop very quickly and there is only a short period of time in which the condition can be effectively treated. Because CES is relatively rare and often follows more typical back pain, ‘red flag’ symptoms may not be recognised.

Missed or delayed diagnosis

When care in the diagnosis and treatment of a spinal injury falls below an acceptable standard, the injuries can affect motor, brain and nerve function.

If the signs and symptoms of Cauda Equina Syndrome are present when attending hospital, a failure to act upon these symptoms within 48 hours, such as arranging for a MRI / CT scan, can be grounds for negligence.

Failed or negligent surgery/post operative complications

The duty of care you are owed as a patient means that every doctor, specialist, nurse or clinician must “exercise the skill appropriate to their experience and training and perform their clinical responsibilities in line with their peers.” 

How Your Legal Friend can help you

No amount of compensation for clinical negligence can reverse the suffering and stress caused when an injury or condition is not properly diagnosed or treated.

No one can truly measure the emotional devastation caused to a patient and their family trying to come to terms with what has happened to a loved one.

As experienced clinical negligence specialists, we know that families need to find answers and hold the people responsible to account. We can help you find out why the system has failed you at a time of greatest need.

You may feel there is an emotional hurdle to overcome before taking the decision to seek legal advice. However, from the first time we discuss your case, our experienced medical negligence solicitors will treat you with the highest degree of sympathetic and sensitive understanding and provide you with the expert guidance you need.

We are committed to ensuring we properly investigate what went wrong and why.  If we can prove your case, we will obtain the maximum compensation for you including loss of earnings, rehabilitation costs, therapy, support, care and specialist equipment, so that your current and future medical treatment and care needs are properly met.