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Posted 8 November 2019
by Endurance Arthur

Who’s to blame when early symptoms of cauda equina syndrome are missed?

Hospital

Where a patient’s early symptoms of cauda equina syndrome were missed by a GP, it is possible to bring about a successful claim, for example with the high court case of Shaw-v-Stead. At Tozers we have seen several cases in which GPs have failed to take an adequate record of the patient’s complaint of early symptoms of cauda equina syndrome and/or a poor history is taken. This has then been made worse by inadequate or no examination of the patient. As a result, the GPs have not given themselves a chance to elicit the appropriate information to recognise the urgency of a patient’s condition. Such patients typically attend complaining of early cauda equina symptoms such as lower back pain, radiating into one or both legs and this is treated as just sciatica and strong pain killers are given. The patients were not warned about “red flags” and recovery is often slow due to the late diagnosis.

When early symptoms of cauda equina syndrome worsen

In one example from our cases, the patient presented again with worsening symptoms of cauda equina syndrome including numbness in the legs. The patient had been seen at a musculo-skeletal clinic and was waiting for an MRI scan to investigate the symptoms of cauda equina further but this was not expedited by the GP. The patient was sent home despite being in such pain that a physical examination was impossible according to the GP’s own note and the patient could barely walk. In a second case, the patient had saddle anaesthesia (another key early symptom of cauda equina syndrome) but this was not elicited by proper questioning. There was no examination and the patient was sent for a hip X-ray. No warning was given to the patient of further early symptoms of cauda equina syndrome which if experienced should prompt them to seek immediate attention in accident and emergency or to call for an ambulance.

When other health professionals miss the early symptoms of cauda equina syndrome

Encouragingly, we have seen some examples of good GP practice when detecting early symptoms of cauda equina syndrome. Unfortunately, this has been thwarted by poor hospital or ambulance service care. In the first example, a GP suspected cauda equina syndrome but when he phoned to discuss the history and his concerns with an orthopaedic registrar of the local hospital, he was assured by the registrar that there was no need for an urgent admission. This resulted in a 48 hour delay before the patient was admitted for assessment, an MRI scan and an urgent operation. By this time the patient was in urinary retention, in other words, the bladder function had deteriorated to the point when they could not start to urinate or if they tried to they could not fully empty the bladder. That patient went on to suffer permanent damage to her bladder, bowel and sexual function. She also suffered permanent mobility problems.

Early symptoms of cauda equina syndrome: timing is key

In another example, a GP suspected cauda equina syndrome based on their patient’s symptoms and advised the patient to call an ambulance for urgent transfer to hospital. The ambulance drivers arrived and put the patient through a series of manouevres and told him he would only be sent home if he went to hospital. The patient therefore remained at home for a further 24 hours in which time he went into urinary retention.

Nice Guidelines for cauda equina syndrome

It is too early to say whether the recent change in NICE guidelines on ‘red flags’ issued in 2018, has made any significant difference to GP practice. We hope that the inclusion of bilateral neurological deficit of the leg as a red flag will prompt GPs to make an earlier referral for patients to be assessed for cauda equina syndrome before saddle anaesthesia and other urogenital deficits become apparent.

Recovery from cauda equina syndrome

If early symptoms of cauda equina syndrome are diagnosed quickly and treated by an urgent operation to decompress the spine, it is possible to make a very good recovery. Unfortunately, where diagnosis and treatment are delayed, significant harm may be suffered such as permanent pain and weakness in the legs, impaired urinary, bowel and sexual function. For some Claimants it may not be possible to return to their usual work and way of life. The consequences of cauda equina syndrome are life-changing, devastating and often accompanied by depression. Should this happen, it may be possible to bring a claim for compensation.

If you believe that your early symptoms of cauda equina syndrome were missed by a health professional, then please contact our specialist medical negligence team on 01392 207020 or email enquiries@tozers.co.uk to discuss this further. For further information on cauda equina syndrome, read our other article here.

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About the author

Endurance Arthur

Partner and Solicitor

Partner and solicitor in the medical negligence department and a member of the Law Society's Clinical Negligence Panel