Portal de Periódicos da CAPES

Cauda equina syndrome: implications for primary care

2014; Royal College of General Practitioners; Volume: 64; Issue: 619 Linguagem: Inglês

10.3399/bjgp14x676988

1478-5242

Jeremy Fairbank, Christian Mallen,

Anesthesia and Pain Management

BackgroundBack 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. 1It 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 types of cauda equina syndromeThere 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.In practice it is not as simple as this.Some slow onset cases reverse after longer delays, but from the legal point of view, these times are widely accepted criteria.CES-R with retention and overflow may not be identified for what it is by patients and their doctors, making careful questioning and clarification of responses essential.Even if it is suspected, the patient may have reached this stage via CES-I.There may be reasonable grounds for complaint for not spotting this process sooner or failure to warn.It is helpful to record when symptoms and signs first started, as this has management and medico-legal implications.