History of CES

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"