Cauda equina syndrome: update to red flag symptoms

The Clinical Knowledge Summaries (CKS) published by the National Institute of Health and Care Excellence (NICE) provide primary care practitioners with readily accessible summaries of current knowledge and practical guidance on best practice in respect of over 330 common and/or significant primary care presentations.

In an attempt to reduce the number of patients left with permanent damage as a result of Cauda Equina Syndrome (CES), NICE have recently made changes to the CKS guidelines relating to sciatica (lumbar radiculopathy).

CES is a serious condition which occurs when the nerves in the spinal canal have been damaged. These nerves control the bladder, bowel, genitals and movement of legs. Symptoms of CES include loss of sensation and pain in one or both legs, numbness and a deterioration or loss of bowel and/or bladder control.

CES mostly occurs in adults and is most commonly caused by prolapsed discs; although there are other causes. A failure to treat CES promptly can lead to long term consequences; therefore, it is treated as a medical emergency. If left untreated, CES can lead to permanent nerve damage, including loss of bowel and bladder control, a reduction in mobility and permanent paralysis and pain.

It is well recognised that a later diagnosis is more likely to lead to an increased risk of permanent neurological deficit, ranging in severity.

Research by the Medical Protection Society in 2016 found that a failure or delay in diagnosis of CES was one of the top five errors that led to the most expensive GP claims.

Previous red flag symptoms for CES were considered to create too high a threshold for urgent investigation, and were not clear enough; resulting in some patients not being referred for treatment or being referred too late.

The updated red flags, which are now more explicit and enable earlier referral, are:

• Bilateral sciatica
• Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
• Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible urinary retention with overflow urinary incontinence
• Loss of sensation of rectal fullness, if untreated this may lead to irreversible faecal incontinence
• Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
• Laxity of the anal sphincter.

Early detection of these symptoms will hopefully lead to a better outcome for patients. Unfortunately, the consequence of these classic signs being ignored or unidentified can be catastrophic for a patient, affecting all aspects of their daily life. GPs and A&E doctors are also likely to benefit from these updates, allowing them to detect CES sooner, making the practice safer for patients.

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