What Makes a Cauda Equina Claim?

Cauda equina syndrome (CES) claims involve proving both breach of duty, or fault, and causation if they are to be successful.

Breach Of Duty

Quite often there is a failure by a doctor to miss a red flag symptom resulting in a failure to diagnose CES, and therefore a failure to refer the patient to hospital for an urgent MRI scan.

The “red flag” signs of cauda equina syndrome (CES) are bilateral radiculopathy, altered perianal sensation and bladder dysfunction. Bilateral radiculopathy is leg pain, numbness or weakness in both legs. Altered perianal sensation includes loss of feeling between the upper legs (saddle anaesthesia), numbness in or around the back passage and/or genitals, and inability to feel the toilet paper when wiping. Bladder disturbance includes inability to urinate, difficulty in initiating urination, loss of sensation when you pass urine, inability to stop or control urine, and loss of the full bladder sensation.

These symptoms often occur in combination with severe back pain, but severe back pain alone or sciatica down only one leg, are not a “red flag” signs of cauda equina syndrome .

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 successfully, the hospital radiologists would not perform MRI imaging after 5.00pm so 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.

Cauda Equina Syndrome Cannot Be Diagnosed By An MRI Scan Alone

Our client was referred for an MRI examination of her lumbar spine by her general practitioner who indicated that she was suffering from back pain and sciatica not controlled by opiate analgesics. The referral information to the radiologist did not give any indication of the neurological deficit or symptoms of bowel or bladder disturbance, she claimed to have reported to her GP, although this was disputed by her GP. Unfortunately, by the time the MRI was reported a month later our client had developed cauda equina syndrome complete (CESC).

On the question of whether the reporting radiologist was negligent, our own expert radiologist pointed out that it was reasonable that her MRI examination was treated with only a modest priority by the radiologist given only the reported failure to control her pain with opiate analgesics, and the absence of clinical signs to suggest cauda equina compression syndrome led to a lower priority for reporting and as a consequence the results of examination was not reported for one month.

In any event our expert radiological expert explained that it must be understood that MRI examination cannot be used to make a diagnosis of cauda equina compression syndrome as this disorder depends entirely on a clinical assessment. The MRI is used to define the site of any compression but cannot determine its functional severity. Therefore, patients with back pain and sciatica but without neurological signs or symptoms may have identical MRI appearances to those that do. It is true to say that patients with disc protrusion that causes cauda equina compression syndrome will typically have a substantial protrusion. However, a substantial number of patients will show similar sized disc protrusions without neurological damage. Therefore, a radiologist reporting an MR examination is not in a position to determine whether cauda equina compression syndrome is present unless the clinician who has examined the patient gives this information in the referral. The diagnosis of cauda equina compression syndrome is a clinical one. The MR examination is used to determine the site of the compression causing the reported CES symptoms and should be undertaken urgently and reported as a priority. However, in patients with low back pain and sciatica but without neurological signs or symptoms the MRI is used to determine the location of the lesion causing those symptoms but without any degree of urgency.

Substandard Operative Treatment

Clinical negligence claims for substandard treatment sometimes arise from low back surgery. An example might be compression caused by a haematoma or by a surgicelloma, where surgicell is used to try to stop excessive bleeding but itself swells considerably. Or nerve roots can be crushed by surgical instruments, compression can arise from metalwork such as laminar hooks or wires, or from retraction whilst obtaining a good exposure.

Causation

The nerve supply to the genitalia and anus are carried by the S3/4 and S5 nerves, respectively. It is known that the smaller nerves carry the sensation and are more susceptible to compression. There are a number of factors, which may affect the results of treatment which include sex, age, previous surgery, disc stenosis and the duration of compression.

The earlier the patient is investigated and treated the more likely that the outcome will be better than if the patient is left with cauda equina compression. The widespread guidelines and teaching are to act quickly whenever this condition is suspected by urgent investigation with an MRI scan and if the condition is diagnosed to proceed to decompression surgery.

Subclassification Of Cauda Equina Syndrome

Cauda equina syndrome is a spectrum progressing from cauda equina syndrome incomplete (CESI), through complete cauda equina syndrome (CESC) to cauda equina syndrome with retention (CESR).

So, as far as causation is concerned, successful claims generally involve proving the claimant would still have been cauda equina syndrome incomplete (CESI) – during which there is retention of voluntary control of micturition however there is altered urinary sensation, loss of the desire to void and a poor urinary stream with straining-if the doctors had operated within a reasonable time.

Unsuccessful claims generally involve CESR, which is cauda equina syndrome with retention – in which the bladder is paralyzed and insensate and then there is either retention or retention with overflow incontinence with a volume of greater than 500mls in the bladder with no pain, or CESC, complete cauda equina syndrome which there is perineal anaesthesia, a paralysed bladder, insensate bowel and patulous sphincter – even if the doctors had operated within a reasonable time.

With claims involving both CESR and CESC even though you might be able to prove the doctors did something wrong, you are not able to prove that if the mistake had been avoided this would have made a difference to the client’s condition or prognosis.

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.