Cauda equina syndrome: implications for primary care.

Back pain is common in primary care. A practice with a population of 10 000 patients will have 610 patients (6% of the practice population) consulting per year, and while poor outcomes are common (around 60% will still suffer pain at 12 months) GPs need to remain vigilant and actively consider more sinister complications. Cauda equina syndrome (CES) is a nasty complication of disc herniation, and sometimes, low back surgery, and rarely spinal tumours (both primary or secondary). While this may be considered a rare condition, Hospital Episode Statistics (HES) data recorded 800 CES related operations in England in 2010–2011.1 It is one of the major causes of litigation in the NHS, both for primary and secondary care. This is not surprising, as a previously fit individual is rendered, in various combinations, and often in perpetuity, incontinent of urine and faeces, with loss of perineal, penile, and vaginal sensation, and major disturbance of sexual function. Self-catheterisation, chronic back and leg pain are often added in to the mix.2 There are two main types of CES: CES-R and CES-I. R is for retention, where there is established retention of urine, and I is for incomplete, where there is reduced urinary sensation, loss of desire to void or a poor stream, but no established retention and overflow. Both need immediate referral for urgent surgery, but CES-R is less likely to be reversible. In CES-I, the time window from onset of cauda equina symptoms to surgical decompression should be <48 hours (some say 24 hours) to have a reasonable chance of reversal. …