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.

It causes symptoms which may be invisible, and also about which the sufferer may feel unable to speak, as they relate to highly personal bodily functions.

Loss of bladder and bowel control can be extremely distressing and have a highly negative impact on social life, work and relationships. There may be frequent urinary infections.

Loss of sexual function can be devastating to the sufferer and his/her partner and may lead to relationship difficulties and depression.

Severe nerve-type (neurogenic) pain may be resistant to treatment and require strong painkillers whose side-effects may cause further problems. If the pain is chronic, it may become "centralized" and affect other parts of the body and involve strange pains such as electric shock type pain or pain from non-painful stimulus such as light touch. This can lead to the sufferer being viewed as neurotic or worse if it is not recognized. It is also very difficult to treat and alarming for the sufferer who either begins to question his/her sanity or fears the pain indicates some terrible underlying undiagnosed disease such as cancer.

Neurogenic pain tends to be worse at night, which can interfere with sleep and thus exacerbate the general debility it causes. Another feature of this type of pain, and a diagnostic one at that, is pain felt in numb areas, which appears to be a contradiction in terms. This tends to be of a burning nature and may be both constant and unbearable.

Sensory loss may range from pins and needles to complete numbness, and may affect the bladder, bowel and genitalia (and therefore exacerbate the problems with these organs).

Weakness is usually in the legs and may make walking difficult. There may be "foot drop" where the foot drags and causes trips and falls. In some cases it may be necessary to use walking aids or a wheelchair.

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, loss of self-esteem. It is entirely appropriate that the sufferer and his/her loved ones may grieve over these losses and they may need considerable support to prevent the most serious loss of all: hope.

TREATING CES:

Acute CES requires urgent surgical treatment if there is a compressive injury.

There may be residual problems after the surgery and these may take some months to resolve. Extensive rehabilitation using physiotherapy and methods such as bladder re-training may be required.

Chronic CES is much harder to treat.

• Pain: usually requires strong painkillers such as narcotics (morphine/related drugs): note that the risk of addiction is very small (around 0.1%) although the body will become accustomed to the drugs and withdrawal symptoms may be experienced on stopping. Adjuvant medication such as low dose an antidepressants (e.g. amitriptyline);. anticonvulsants ,.(e.g. Tegretol; (carbamazepine) neurontin(Gabapentin) are often helpful. Side-effects should tend to subside after the initial couple of weeks, constipation being the most persistent side-effect of opiates and weight gain being common with the adjuvant medication. The sedative effects of some medication may be beneficial if given at night as they may aid restful sleep. However, antidepressants may adversely affect bladder and sexual function and contribute to the problems experienced. It may be a delicate balancing act to achieve good pain relief with the minimum of adverse effects.

• Bladder Control: depending on the exact nature of the problem, a neurogenic bladder will need to be treated with drugs such as Oxybutynin if it is hyper-reflexive, or intermittent self-catheterization if the bladder is unable to empty. The latter may give rise to a residual volume of urine in the bladder after voiding and this causes susceptibility to urinary infections that may require antibiotic treatment. An overactive bladder muscle(detrusor) may cause high bladder pressures and a reflux of urine up towards the kidneys, so regular checks may be needed to exclude any kidney damage. Use of measures such as cranberry juice and maintaining good fluid intake may reduce the risk of infection. Often pads may need to be worn in the underwear to protect against leakage of urine. This of course, may be distressing and embarrassing for the sufferer.

• Bowel control:not only loss of control of feces may be a problem, but also of flatus and the inappropriate, uncontrollable passage of gas at inconvenient occasions may be a source of considerable embarrassment to the sufferer. Fecal incontinence of loose stools may in fact be helped, coincidentally, by use of painkillers such as codeine or morphine as they tend to be constipating. However, extreme constipation causing impaction of feces can lead to overflow of diarrhea around the impacted fecal mass. Most commonly in CES, it is difficult to empty the bowel, sensation in the rectum being diminished and propulsive action reduced. It is often necessary to assist the bowel to empty and there are a variety of methods available. Eating a high fiber diet and maintaining good fluid intake are useful general measures and using a stimulant laxative on a regular basis can facilitate matters.

• Weakness: physiotherapy may be helpful provided that there is no inflammatory component, as in arachnoiditis, where exercise may exacerbate the condition and cause a "flare-up."

• Sexual dysfunction: very difficult for people to discuss. It may be best to seek advice from specialists in this medical field; if no physical treatment is feasible for improvement of function, then the sufferer (and his/her sexual partner if appropriate) should be offered counseling, which may help lessen the impact this disability could have on the sufferer both as an individual and as part of a couple.

• Sensory loss: there is little conventional treatment but in conditions such as MS, use of vitamin B complex is considered to have possible beneficial effects.

• Sore feet: loss of muscle tone and control over movement of the foot may lead to pain in the foot. If foot drop is a significant problem, a brace to hold it in position may be helpful. However, it is important to try to maintain as much muscle tone as possible and range of movement (ROM) exercises may assist in this.

• Poor circulation: this is quite a common problem: the feet may be cold and may turn white, then red when rewarmed(Raynaud’s syndrome) as well as chilblains: there are some medications that can be taken, but it is probably best to use general measures such as avoiding getting cold feet (thick socks etc.) and also foot massage with warm oil may help improve circulation. Avoid very hot baths after the feet have been cold as this is more likely to cause chilblains.

• Depression: this being an understandable and normal reaction to a debilitating illness, antidepressant medication should be reserved for severe depression, the preferred management being counselling and support. The sense of isolation may best be addressed by contact with support groups such as the online Cauda Equina Syndrome Support Group,(CESSG). These groups perform a vital role in allowing free and frank discussion: ‘mentioning the unmentionable’. Shared experiences can help sufferers to come to terms with the disabilities CES causes them.