• Nunn N
• Gregory C
• Battiston A
• Breeze S

• Cauda Equina Syndrome
• Manipulation, Spinal
• Open Access Document
• Patient Care

Background: Low back pain is a condition that is treated by chiropractors, osteopaths, and physiotherapists who use manipulation as one of their therapies. One presentation of low back pain is a disc extrusion or sequestration. Here the disc material has ruptured through the annular fibres and because of its acidic nature starts to damage the nerve root and can lead to cauda equina syndrome (CES). This paper explores this documented cause of CES with final year chiropractic students who are in a primary contact position. It describes whether they screen for signs and symptoms of CES and ask the appropriate questions leading to correct referral pathway. We review iatrogenic causes of CES by professionals who use manipulation, and ask does the literature support this effect? If signs and symptoms are not diagnosed, it can lead to a life-changing future for the patient and result in a legal process and an insurance claim. Professions treating low back pain must be vigilant and constantly screen for CES. 

Intervention: Two cases presented to the AECC University college Chiropractic (AECC UC) Teaching Clinic are reviewed. Final-year students see patients in their placement year as part of their training. They take a detailed history and physically examine the presenting complaint. Low back pain is a common complaint presented by patients at the AECC UC Chiropractic teaching Clinic. Are Cauda Equina Syndrome (CES) questions asked during the initial consultation and treatment? The required routinely asked questions are as follows: Has the patient experienced any of or a combination of the following signs and symptoms: saddle anaesthesia, nerve root pain, sexual dysfunction, bowel disturbance, bladder disturbance and relevant medical history relating to a previously diagnosed CES? 

Outcomes: The findings from the case reports suggest that chiropractic students supervised by registered chiropractors are good at recognising CES signs and symptoms either initially or ongoing, through a course of treatment and are following the modified NHS guidelines for referral with the AECC UC CES pathway. The literature refers to a mechanical cause of CES due to lumbar spinal manipulation. According to the current literature lumbar spinal manipulation delivered by a registered professional for low back pain is not a risk factor for CES. 

Conclusion: Patients with low back pain may have an elevated risk of cauda equina syndrome independent of manipulative treatment which is not considered a risk factor. Therefore, students and clinicians treating lower back pain patients are ideally placed in clinical settings to identify cauda equina syndrome signs and symptoms and should always be aware of any deterioration in presentation and review CES signs and symptoms and use the appropriate clinical pathway. 

Author keywords: Chiropractic; Cauda equina syndrome; Chiropractic adjustment; Manipulation; Care pathway.

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