By Dr. Biodun Ogungbo
Nobody told me I would feel like this. Nobody told me I would cry every time my husband and I make love. Nobody told me that I would need to wear a diaper. Nobody told me maybe you should have bladder and bowel therapy. Nobody told me I wouldn’t be able to concentrate or think about other things. Nobody told me you will need counselling to help deal with all of this. Nobody told me about CES. Poem by Marion Hatten.
The patient
The patient is a 24 year old woman who slipped in the bathroom a while back. She felt a sudden severe pain in her lower back and was unable to walk. The pain was excruciating and shooting down her legs. This was a kind of pain she had never felt before. She had to be carried to the first hospital where she stayed for 3 weeks. The doctors applied a bandage called skin traction to her legs. Ostensibly, this was to help ease the back pain and keep her in bed.
Unfortunately, while on the traction she developed problems with passing urine and stool. Her bottom also became numb. Her orthopaedic doctors reassured her that it was normal since she was lying down. Apparently, some people cannot urinate or pass stool lying down! They also said it was a sign of ‘healing’: as she deteriorated on the ward. Anyway, she discharged herself from the hospital and found another one. Here, finally, she was asked to undergo an MRI scan to find out what was going on.
The MRI scan revealed she had a huge bulging disc in her spine causing pressure on her nerves. The prolapsed disc was damaging the nerves that supply the bladder, bowel and her private parts. She was then referred to a third hospital!
The Cauda Equina
The cauda equina (horse’s tail) is so-called because of its appearance. It looks like a horse’s tail and is found at the lower end of the spinal cord. It contains the nerves involved in moving the legs, and the nerves that supply sensation to the anal and genital regions. Any damage to these nerves can result in permanent injury to these areas causing the syndrome.
Cauda equina syndrome (CES for short)
The syndrome arises through nerve damage to the cauda equina. There is a specific pattern:
• Severe pain in the buttocks, anal area, genitals, thighs and legs.
• Loss of sensation: often tingling or numbness in the anal area and genitals.
• Weakness: in legs, often affecting one of both legs.
• Bladder/bowel/sexual dysfunction: incontinence / retention of urine; incontinence of faeces; impotence/loss of ejaculation or orgasm.
CES is a devastating condition which can damage many aspects of life. Often, the sufferer can no longer continue to work, either from severe pain, or because of loss of muscle power, or due to socially unacceptable continence problems, or indeed a combination of these problems. Loss of bladder and bowel control can be extremely distressing and have a highly negative impact on social life, work and relationships. Loss of sexual function can be devastating to the sufferer and his/her partner and may lead to relationship difficulties.
Bearing in mind these problems, it is unsurprising that sufferers may become depressed; they endure many losses: loss of health, loss of job and social standing, loss of relationships, loss of sexuality and loss of self-esteem.
Management of serious back pain
Patients with severe back pain must be carefully evaluated for signs of nerve damage. Problems with walking, numbness in the legs, numbness in the private parts, difficulty passing urine or stool and problems with erection are clear signs of nerve involvement.
Urgent x-rays to rule out fracture or tumours are important but the definitive investigation is an MRI scan: to actually diagnose the cause of nerve injury. Radiologists should signify the severity and impress that urgency is required. In management, traction especially skin traction with bandages on the legs is a stupid and archaic idea. It is of no benefit in today’s evolved medical practice. Bed rest in hospital without diagnosis and clear treatment plan also does harm.
Urgent referral to a spine surgeon is vital so the nerves can be protected and prevented from permanent injury. Surgery is of the essence in many cases and should be carried out expeditiously. There may be residual problems after delayed surgery and these may take some months to resolve. Extensive rehabilitation using physiotherapy and methods such as bladder re-training may be required.
The advocacy
Medical and public awareness of CES needs to be significantly raised. The set of symptoms and signs is a medical emergency and should be recognised and treated as such by doctors and patients.
Doctors need to treat such patients with despatch to prevent harm. You do not joke with a condition that affects the ability to pass urine, pass stool or which causes numbness in the private parts. Delay can lead to permanent disability. Please share this article widely as no one needs to become a social pariah.
Next week: All the lies about staphylococcus and toilet diseases.
