Causes and outcomes of cauda equina syndrome in medico-legal practice: a single neurosurgical experience of 40 consecutive cases

Background: This is a unique report of 40 patients litigating in relation to the management of a cauda equina syndrome (CES), with prospective data collection. Methods: Patients were seen and examined; medical records and radiological imaging were reviewed. The following data were collected prospectively: age; sex; the level of cauda equina (CE) compression; the pathology causing the compression; the clinical picture at first presentation; the causes of any iatrogenic injury; possible breaches of duty of care and the responsible discipline; recovery of bladder control; return to work. Findings: There were possible breaches of duty of care for 39 patients initially, and for 69 patients overall. Twenty-eight patients presented with compressive degenerative pathologies (mainly central disc prolapses); all 28 had deteriorated to the point of bladder paralysis (complete CES (CESR)) at the time of treatment. Twenty-six (93%) had voluntary bladder control at presentation. Long-term bladder paralysis was probably avoidable in over 90% of patients. Eleven patients had iatrogenic injuries: all had long-term bladder paralysis. Thirty-four patients had bladder paralysis (CESR) at the point of decompressive surgery. Recovery of bladder function occurred in only seven patients (21%), i.e. long-term bladder outcomes were poor. Only 22% of patients returned to work. Conclusion: In this highly selected group of patients whose CES was not managed in an appropriate/standard fashion, 93% of patients had long-term bladder, bowel and sexual dysfunction that was probably avoidable. Mismanagement of patients with iatrogenic injuries was associated with a universally poor outcome.