Clinical Negligence – Cauda Equina Syndrome Claims
Cauda Equina Syndrome (CES), a rare disorder affecting the bundle of nerve roots at the lower (lumbar) end of the spinal cord, is a surgical emergency.
It occurs when the nerve roots are compressed and paralyzed, cutting off sensation and movement. Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage.
Cauda Equina Syndrome (CES) has ruined the lives of many of our clients, who often suffer urinary or faecal incontinence, loss of sexual sensation, leg and back pain together with immobility.
If patients with cauda equina syndrome do not get fast treatment to relieve the pressure by a discectomy, which is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord, it can result in permanent paralysis, impaired bladder and/or bowel control, loss of sexual sensation, and other problems.
Cauda Equina Syndrome Claims
Cauda equina syndrome claims can follow a delayed discectomy and be directed against the hospital doctors. The usual error is late diagnosis and failure to explore the operative level after first performing an MRI scan. However, another cause of cauda equina syndrome claims can be nerve root damage from cutting or undue retraction due to careless technique during the operation. A claim is directed against the Hospital Trust that employs the doctors or surgeon.
Another example of cauda equina syndrome claims is one brought against a GP who fails to recognise symptoms and to refer the patient immediately to a spinal consultant for an MRI scan and then an operation.
Cauda Equina Syndrome – Red Flag Symptoms
To establish fault , or breach of duty, depends solely on whether you had any red flag symptoms ( perineal numbness (around genitalia), urinating feels different, such as urinary urge, hesitancy & poor stream (not a continual flow), bilateral sciatica rather than sciatica in just one leg, severe or progressive bi-lateral neurological deficit in the legs such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion ) in the days before or the day you saw your GP , and whether there was also unreasonable delay by your GP in failing to refer you then immediately to hospital for an urgent MRI scan that day , which if CES was confirmed would then be followed by a spinal cord decompression operation that day.
Urinary or faecal incontinence or retention, so far as a successful claim is concerned which needs to establish incomplete cauda equina syndrome at the time you are seen by your GP, aren’t helpful red flag symptoms because they usually mean that symptoms have progressed beyond the point where operating swiftly will make any difference to the outcome.
Neurological deficits have to be present in both legs, rather than just one, to be red flags.
Ideally the medical records, rather than your witness statement alone, will corroborate the presence of the red flag symptoms as reported by you to your GP. Otherwise it is your word against the doctor’s word supported by the medical records. Also, multiple red flag symptoms help, as you would normally expect symptoms of peri-anal numbness to be accompanied by urinary symptoms.
Back pain alone, no matter how bad, is not a red flag symptom as many people have slipped discs causing back pain, but only a tiny fraction go on to develop cauda equina syndrome. Instead it would be reasonable in a scenario say of really bad back pain, for the GP in addition to referring you for an urgent MRI scan, which might take several days to happen, to also refer you for an urgent assessment at a Musculoskeletal Clinic, but with the proviso that the GP should also ‘safety net’ by informing you about the red flag symptoms and signs of cauda equina syndrome which, if they developed whilst you were awaiting the urgent MRI scan and musculoskeletal appointment, would instead mandate you going immediately to the A&E Department to seek urgent medical attention. Failure to safety net would also be a breach of duty by the GP.
Alternatively, a claim can be based on a failure by doctors to warn about red flag symptoms for CES if this causes disastrous delay in the patient attending hospital when these symptoms appear.
How We Can Help
For over thirty years Solicitor, David Dickie, has specialized in this area and achieved substantial settlements for clients as a result of successful litigation. For more information on pursuing a claim, please contact David on freephone 0800 011 6666 or via email at d.dickie@timms-law.com.
Detailed below are a couple of case studies, more can be found here.
Case Study 1
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 8.20pm 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 14.45pm 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.
Case Study 2
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-MacDonald 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.
