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Missing cauda equina

14 September 2014

Ms E, a 29-year-old mother, had suffered with ongoing low back pain since the birth of her second child two years ago, which had failed to improve with physiotherapy. She was assessed in orthopaedic outpatients and diagnosed with an L5 disc prolapse and listed for microdiscectomy.

A week after her orthopaedic consultation, she called her local GP surgery and spoke to Dr A, complaining that she was still in pain, and was unable to come down to the surgery to be seen. Dr A noted she was waiting for an operation and gave further analgesia and muscle relaxants.

The following day, Ms E called the out-of-hours service reporting ongoing pain, despite taking the analgesia prescribed by her GP. She also mentioned numbness in her left leg. The triage nurse she spoke to advised her to try an anti-inflammatory and to seek further advice if her symptoms worsened or if she continued to be worried.

Ms E continued to have symptoms so booked an appointment to see Dr A, and was seen three days later. Her pain was ongoing and she had now developed urinary symptoms; Dr A added in naproxen and started antibiotics for a suspected UTI.

The prescribed medication made no difference to her symptoms, and the following evening Ms E presented to her local emergency department, and was diagnosed with cauda equina syndrome. She was transferred to the care of the neurosurgeons and had an urgent MRI. She underwent an L4 laminectomy the following afternoon, but was left with irreversible disturbance of bladder and bowel function and a persisting numbness in both the left leg and the perineal region.

Ms E pursued a claim against Dr A, alleging that he had failed to warn her about the seriousness of red flag symptoms in his first two consultations with her. She also claimed that he had failed to carry out any clinical assessment or suspect cauda equina syndrome and refer appropriately when she had presented at the surgery.

Expert opinion

MPS experts reviewed Dr A’s case notes. The GP expert felt that Dr A had not breached his duty in his initial telephone consultation by failing to warn Ms E about red flag symptoms, on the basis that she was under the care of the orthopaedic team and it was reasonable to assume that they had advised her about cauda equina syndrome and its symptoms. However, his subsequent consultations were viewed as substandard. His note-taking was poor and he failed to document any enquiry about red flag symptoms when the patient presented with urinary symptoms on a background of back pain. Dr A conceded that his usual practice was to document a lack of red flag symptoms if he asks about them and, therefore, it was likely he did not ask and that his diagnosis of a UTI would be difficult to defend.

The neurosurgical expert felt that the onset of cauda equina began with the urinary disturbance, which Ms E consulted Dr A about, and that an urgent referral for surgery within 48 hours of the onset of symptoms would have resulted in a more favourable outcome. He stated that the claimant was likely to have been left with residual low backache without bladder and bowel symptoms or neurological symptoms, and that Dr A’s failure to diagnose cauda equina syndrome led to a significantly less favourable outcome for Ms E.

The claim was settled for a high sum.

Learning points

  • As always, good note-keeping is essential – not only for patient care, but when defending a claim. When assessing any patient, negative findings should be routinely documented, and in cases of back pain, repeated examination is often necessary to ensure there are no developing or progressing neurological symptoms.
  • Cauda equina syndrome comes up repeatedly in Casebook. Be wary of patients who re-present with ongoing pain and never forget to ask about red flag symptoms (see useful links). In the setting of acute back pain, bowel and bladder symptoms should always prompt careful consideration of a neurological cause.
  • It is easy to be reassured when a patient has seen a specialist and is awaiting further treatment, but symptoms can change, and an enquiry should be made about any deterioration in each new contact with the patient.

Useful links

2 comments
  • By Dr Marimuthu velmurugan on 02 April 2015 04:48

     Avery good valid point every GP should know. I always ask bladder and bowel symptoms and any disorder encounterd by patient as new problems. I must make it  a point to record it legibly,

    a very good example.

    Kind regards,

    Drvel.

  • By Dr.s.z.Haider on 02 April 2015 03:11 This is very good case for learning red flag symptoms in back pain symptoms as ingen practise ten percent patient consultation are with back pain and some timesit is dificult  in10 minutes consultation to assess such patients and it is wise to review the patient Asa special time slot at the end of surgery for detail neurological assessment specially whenpt presents with urinary or bowel symptoms
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