Cauda Equina Syndrome Case Studies
With over 30 years experience, Clinical Negligence Solicitor David Dickie, shares some of his Cauda Equina Syndrome (CES) case studies…
CES Case Study 1
A cauda equina syndrome claim conducted by David Dickie arose from a laminectomy during which there was damage to many nerves due to failure to remove enough bone to work safely. A report was obtained from an orthopaedic expert, Mr Mann, supporting this but liability was denied, and proceedings were issued. Many other reports had to be obtained, including from a urologist, on the claimant’s double incontinence, and a neurologist on her nerve damage which included saddle anaesthesia.
To support a re-housing claim an architect‘s report was obtained. Other reports were from a psychiatrist, an occupational therapist, a nursing care expert, an oncologist, and an employment consultant. The claimant’s pre-accident life expectancy was in dispute due to her previous lumpectomy and the multiplier for her lifetime losses was heavily contested. Due to the multitude of experts, a fixed date trial had to be listed. Shortly before trial in 1998 a settlement of £250,000 was concluded.
CES Case Study 2
This was a cauda equina syndrome claim resulting from surgical, a haemostatic agent, being left in situ despite the manufacturer’s instructions. After a laminectomy/discectomy complicated by bleeding during the operation, and post operatively, there was a negligent failure to diagnose and act upon neurological deficits caused by a surgiceloma, a swollen mass of blood and surgical, which was pressing on the spinal canal, so that even after a decompression operation to remove the surgiceloma, the claimant was left virtually paraplegic. Numerous reports were obtained, and the claim settled on the eve of trial for £400,000 by David Dickie.
CES Case Study 3
The only way to confirm the diagnosis of CES and to make a decision on whether it is necessary to operate to decompress the spine is to get an emergency MRI scan. To diagnose CES there needs to be easy access to out-of-hours MRI scanning available to all relevant clinicians at the same hospital, but unfortunately this was recognised as a nationwide problem by the National Spinal Task Force.
In a case David Dickie litigated, the hospital radiologists would not perform MRI imaging after 5.00pm. The decompression operation was put off until late the next morning so a scan could take place beforehand, by which time it was too late to avoid the devastating neurological damage to the claimant.
Our neurosurgical expert pointed out that must have been known to the spinal service and therefore it was essential that there was an immediate request to the radiologists to perform emergency MR imaging. Our expert would have expected emergency MR imaging to have been performed at the hospital as an emergency prior to close of play. However, as the request was made shortly before 5pm and the radiologist had said that MR imaging could not be performed out-of-hours, there should at least have been an emergency referral to another service for emergency imaging and treatment to be performed. The case settled for £795k.
CES Case Study 4
On 15th June 2011, the Claimant was admitted to hospital. Over the next couple of days the doctors failed to recognise, and act appropriately having regard to, the fact that his neurological symptoms were deteriorating significantly. An MRI scan was not carried out until 19th June 2011, but they failed to consider the results until 20th June, and then unbelievably failed to recognise that the scan showed compression of the cauda equina nerve, instead discharging him from hospital on 21st June. Not until he was re-admitted on 25th June was decompression and discectomy surgery at L4/5 was then carried out, but by then it was too late to make a substantial difference.
The Claimant was subsequently left with permanent neurological symptoms comprising complete numbness in his right leg, buttock and saddle area, loss of sexual function, bowel and bladder incontinence, neuropathic pain in the right foot, moderate numbness and pain in the left foot, right hip and thigh.
A Consultant Orthopaedic Surgeon prepared a Breach of Duty & Causation Report which advised that the Claimant should have had a priority scan by 17th June 2011 and that the same would have demonstrated a substantial disc prolapse compressing his Cauda Equina. He considered that the spinal service should have been contacted on 17th June and surgery taken place by 18th June. And it was his belief that if the Claimant had had surgery by 19th June 2011, the Claimant would have been left with virtually normal bladder and bowel function, the weakness in his right lower limb would probably have improved by 1-2 muscle grades. It was believed that the Claimant would have been left able to walk without a foot drop splint except for long distances.
Proceedings were issued by conducting solicitor, David Dickie, as the Defendant sought to defend the claim on the basis that given his symptoms then, it was reasonable to discharge the Claimant from hospital on 21st June 2011 with an outpatient appointment to follow. They also sought to reduce the size of the claimant’s loss of earnings and other claims by introducing expert evidence that his diabetes and other pre-existing health issues significantly reduced his life expectancy. However substantial damages were obtained in a settlement shortly before trial.
CES Case Study 5
The Claimant first experienced sciatica in January 2015 and then low back pain in July 2015. She was in so much pain on 15th October 2015 that she was taken by ambulance to hospital and was put on a morphine drip. She was told her pain was sciatica and was sent home the next day for GP follow up.
She then had an MRI scan at a different hospital on 5th November 2015 which was reported as showing a very large posterior L4-5 disc prolapse flattening the theca. On Wednesday 9th December 2015 an ambulance took the Claimant to another hospital where she arrived at 6pm as her leg pain had gradually got worse and she had numbness across her pelvis, down her left leg and left foot. She had also felt altered sensation when urinating and wiping afterwards.
At around 7.30pm an Accident & Emergency doctor did a rectal examination with a chaperone present and found normal tone, but this was incorrect as the Claimant asked if he was touching her as she couldn’t feel the examination. She was discharged by the doctor with a diagnosis of sciatica with no evidence of CES.
The following day the Claimant couldn’t feel either leg as well as part of her saddle area. She had been left totally confused by what the Doctor had said and didn’t want to make a nuisance of herself by going back to hospital so around 8.30am she called her GP surgery again. A GP went to see her at 11.45 and told her she needed to go to hospital straightaway. The GP called the hospital and spoke to the neurosurgery department there and gave her a letter to hand in.
She arrived at Hospital at around 2.45pm and handed the letter in. The spinal department were beeped but she had to wait around 3 hours in A & E in a wheelchair. She was seen at 6pm by an Orthopaedic Doctor whose examination found decreased light touch sensation in her perineum. The Claimant had an MRI scan at about 7pm on 10.12.15 which at about 8.20 was discussed with the orthopaedic team as being consistent with CES within the right clinical picture. However, a L4/5 decompression and microdiscectomy operation wasn’t carried out until 14.45 on 11.12.15.
The Claimant’s case was that her CES symptoms were symptoms which mandated emergency assessment and treatment, there was unacceptable delay in her being assessed and treated and she had suffered irreversible injury as a consequence. The Defendant’s medical and/or nursing and/or administrative staff breached their duty of care to the Claimant.
The Defendant hospital admitted Breach of Duty and with regard to causation admitted that it was more likely than not that the Claimant would have come to surgery on the morning of 10th December 2015 had she been referred to the neurosurgical team when she attended Accident & Emergency on the evening of the 9th December 2015. However, it was admitted only that the Claimant would have avoided an additional day of pain and suffering, the extent of which was not admitted. And on causation the Defendant denied that earlier surgery would have given the Claimant a better outcome in terms of her alleged ongoing symptoms.
Proceedings were issued by David Dickie and after protracted litigation a settlement of substantial damages was obtained.
CES Case Study 6
This was a CES claim litigated by David Dickie arising out of the defendant hospital’s delay in carrying out a decompression operation on a haematoma that developed after spinal surgery. It was a high value claim as there were substantial claims for care and re-accommodation. Proceedings were issued and the claimant eventually obtained a very large settlement.
Although breach of duty was not accepted by the hospital , as an unreasonable delay was denied , the main dispute was over causation because with slipped disc spinal cord compression cases where the compression damage to the nerves progresses as far as Cauda Equina Syndrome Retention (CESR), which is painless urinary retention and overflow incontinence , it is generally accepted by medical experts that it is too late to operate to make a difference to causation. Put another way, in patients with cauda equina syndrome with retention the clinical outcome is poor anyway and bears no relation to timing of surgery.
The Claimant’s causation argument was supported by expert orthopaedic evidence from Mr Wilson-Mac Donald that although the Claimant symptoms suggested he was CESR, since his compression was caused by a haematoma it had a different pathology than that caused by a slipped disc and therefore it could be operated on and decompressed within 12 hrs to make a full recovery, in contrast to CESR caused by a slipped disc.
The supporting cutting edge expert evidence of our consultant neurosurgeon, Mr. Todd, actually went further as it was to the effect that the limited evidence available suggests that the prospect of recovery in all CESR patients treated within 12 hours may be favourable, not just those where compression was caused by a haematoma , as this appears to be the case for the Spinal Epidural Haematoma (SEH) patients, but this lacks scientific proof for the central disc prolapse/CESR patients, as is also the case for the SEH literature.
How We Can Help
Cauda Equina syndrome claims are technically complicated and it is therefore important to instruct an expert, such a David, to pursue your claim. By dealing with each claim personally, from start to finish, on a no -win, no fee basis, not only will he successfully maximise your prospects of success, but also the amount of damages you obtain. David is a member of Action for Victims of Medical Accidents’ (AvMA ) Clinical Negligence Panel, who has over 30 years of experience specialising in litigating cauda equina syndrome claims.
David Dickie, is renowned both for achieving many high value settlements of Cauda Equina Syndrome claims and for his client empathy. He can be contacted on freephone 0800 011 6666 or via email at d.dickie@timms-law.com
