The History Of Cauda Equina Syndrome
How the Nerves work and are affected by CES.
The earliest case of Cauda Equina Syndrome was caused by manipulation of the
lumbar spine under general anaesthetic. The National Spinal InjuriesCentre at Stoke Mandeville Hospital, in the UK.
Mr Jonathan Hutchinson described a 42-year-old man with a previous history of alternating sciatica who had
been crushed under a pile of timber and while under ether anaesthesia in 1889 the manipulation took place. When
the patient awoke from the anaesthetic, he had paralysis of his bladder and bowels. Mr Hutchinson could not establish
a diagnosis. Evidence is presented to suggest that this was the first case of a prolapsed disc causing a Cauda Equina
lesion as a result of anaesthesia and manipulation. There has been considerable interest in spinal injuries which have
arisen as a result of anaesthesia and chiropractor manipulations. I have identified a case described by Mr Hutchinson in
1889 who was not only a distinguished Dermatologist and Surgeon, best known for his Eponymous description of
Hutchinson's teeth in congenital syphilis but also an important neurologist, contributing particularly to the field of spinal
injuries. Mr Jonathon Hutchinson was a surgeon to the London Hospital where there was a great neurological
tradition. Dr James Parkinson who gave the first description of Parkinson's disease, was a student there as was as Mr
Henry Head, Sir Victor Horsley, and Mr George Riddocch.
|Mr James Parkinson||Mr Henry Heard||Sir Victor Horsley||Mr George Riddoch|
All these renowned men practised neurology at the well-known and renowned London Hospital. In a little-known
paper, Hutchinson gave a series of accounts of the clinical manifestations, treatment and pathological findings of a
series of patients with spinal injuries. Many patients survived and left the hospital ambulant, having sustained a severe
injury of the spinal cord. These patients were treated with intermittent catheterisation. Mr Hutchinson stated
categorically that the injury to the spinal cord was due to direct trauma at the time of injury, and not due to a
haematoma compressing the cord. He reiterated the views of Dr Bell also a prominent Neurologist and Surgeon,
on the dangers of carrying out a laminectomy, he recorded the dangers of pressure sores and recommended the use
of a form of the waterbed to prevent them. His views are modern and he draws attention to how badly
patients are examined and how one should be sceptical of clinical observations, which has modern resonance. Another
source of the fallacy is the difficulty of accurate observations on spinal injuries in 1889. A man tells
you “I cannot move my legs'' and you are unable to prove the contrary, though it is still possible that a very vigorous
exertion of will might be able to set certain muscles in action; in other words, that voluntary motion, although
seemingly in abeyance, is not absolutely lost. The same patient tells you that he “feels well'' yet if you try accurate
tests, such as the compasses or drawing a feather over the surface, needle function on groin and legs, you will find
that his sensory function is very far from perfect. On account of our frequent neglect of such tests, we are compelled
to receive with many qualifications, recorded statements as to “perfect sensation being retained after those sort of
accidents”. The only reference to this work is by Dr J. R. Silver and Mr Hutchinson’s contribution to spinal injuries is
not mentioned in modern reviews of the subject. Mr Hutchinson was recognised as a renown and component
neurologist since he delivered a concise report to catheterise him three times a day. He had no pain and could not
appreciate the passage of a catheter. Once the Urethral catheter had been inserted, the gentleman became was
constipated immediately three days postoperatively and on the third day after the operation, he was faecal incontinent
without any feeling. He was seen by M. Hutchinson six months later when the examination showed the anus to be
patulous and anti-contractile. There was no contraction of his lower bowel and an enema had to be used or he had to
be manually evacuated. He was unaware of the passage of faeces. When he catheterised himself three times
a day, he had no sensation on the passage of the catheter. The only way he could empty his bladder was by straining.
He had partial anaesthesia around the anus and buttocks.
Hmmmm, This could be CES, what are the "RED FLAGS" ?
I think I will be safe, and order an MRI.
He had no problems with his bladder or bowels prior to the operation but he did have a previous history
of alternating sciatica on both sides which was not very common and during the attacks of sciatica, he felt numb on
the buttocks. There is no record of the state of the muscles of his lower limbs. Mr Hutchinson diagnosed a form
of ascending neuritis initiated by crushing of his spine but he was unhappy with this since there was no interval
between the operation and the development of retention. There is no further information. No operation was
performed and X-rays were not described until 1895. Anatomically he had a lesion of the Cauda Equina.
In retrospect, the most likely diagnosis is that he had a large lumbosacral central disc which was impinging on the
Cauda Equina and, under the anaesthetic and the manipulations attendant on crushing the spine, the disc
prolapsed and caused a Cauda Equina lesion. The features to substantiate this diagnosis are a previous history of
alternating sciatica accompanied by anaesthesia around the anus and the profound bladder and bowel
involvement following an anaesthetic.
Against it is the observation that there was no history of back pain at any stage but this is not unusual and is well
recognised by spinal surgeons today, that there may be no pain at all but this is followed by the numbness
or pins and needles feeling in the saddle or leg/s areas. The clinical features of Cauda Equina Syndrome caused by
disc prolapse were summarised by Dr Bryan Jennet in 1972. Sphincter involvement was common in half the
cases. There was a history of repeated attacks of backache and sciatica for many years. In two cases the sciatic pain
had been bilateral and in two others it had alternated between the two sides. Bilateral symptoms and signs
commonly preceded serious compression and indicated its imminence, and could well be precipitated by sudden
movement. The onset of compression was sudden in twelve cases. In other cases, the paralysis came on whilst the
patient was resting in bed.
One patient developed paralysis during a game of cricket, another gave a violent cough whilst in bed with sciatica
and was immediately aware of numbness and paralysis of both legs and had sphincter paralysis, whilst the
third patient had a profound Cauda Equina paralysis immediately after manipulation of the back by a Chiropractor for
long-standing sciatica. It can thus be seen that a Cauda Equina Lesion can be precipitated by quite minor trauma or
manipulation such as was experienced in this patient. There is a large literature of spinal cord injuries following trivial
manipulation of the spine either by a chiropractor or by an accident or crushing pressure upon the lumbar area. There
was stated by Jenner a patient who had bilateral pain down both thighs. Initially, he was treated conservatively.
He then had an ether anaesthetic and woke up with a Cauda Equina Lesion. Mr Fisher and Dr Richard both
Neurologists/Spinal surgeons reported cases of Cauda Equina Lesion following manipulation of the spine by a
chiropractor in which the diagnosis was confirmed by laminectomy. In this case, the pathology is unknown. The
patient had a previous history of alternating sciatica and when he woke up from the anaesthetic, he had profound
bladder and bowel involvement with anaesthesia around the anus. On the balance of probability, this was not a
coincidence but follows a similar pattern to those described. When the patient has an anaesthetic, manipulation
takesplace to position the patient. The muscles are relaxed. It is known that patients who have had anaesthetics to
have a baby delivered and have woken up with a Cauda Equina Lesion. In these cases, the diagnosis was
substantiated by myelography and at laminectomy. Since Dr Bryan Jennet’s work the diagnosis of Cauda Equina Lesion
has become more stringent, i.e. injury to the lumbosacral nerve roots within the neural canal resulting in the
bladder, bowel, and lower limbs paralysis. Mr Hutchinson's patient had alternating sciatica, a double sphincter
paralysis, and anaesthesia around the anus and would fulfil these criteria.
Clearly, the syndrome can be caused by other conditions such as ossification of the posterior longitudinal ligament,
spondylosis deformans or spondylolisthesis. There are no radiological, post mortem findings or operative findings to
substantiate the diagnosis, but from the clinical features and mode of production, Mr Hutchinson's case would appear
to be the first case of Cauda Equina Lesion caused by manipulation and anaesthesia in the literature. We are fortunate
that Mr Hutchinson made such acute observations which, even today, enable one to postulate on the possible
mechanism of the extent of the injury. To continue with the history the following is flow on and although have brief
explanations are expanded on further within different sections. Please note that some items may be repeated but it is
important to realise the symptoms can produce other problems.
Dr Brian Jennet Dr Bell
Nerve Set Up - Low back pain
As Baby Says "Know the History of this Disorder"