Cauda equina syndrome news

 

Cauda Equina Syndrome - A Cause for Concern

Back in March I commented on a warning that was issued by the Medical Defence Union (MDU) to GPs in relation to cauda equina syndrome (CES).

Since 2005, the MDU, which provides representation and indemnity to doctors, had paid out £8 million in compensation to patients who had been disabled as a result of delayed diagnosis and treatment of this serious neurological condition. The MDU’s warning reminded doctors that cauda equina is a medical emergency requiring prompt recognition and action when a patient presents with red flag symptoms.

More recently, another of the leading medical defence organisations, The Medical Protection Society (MPS), has included failure and delay in diagnosis of cauda equina syndrome in its list of the top five areas of general practice which give rise to the most expensive negligence claims. CES featured at the top of the list, which was based on the MPS’s own claims data, according to their report, The Rising Cost of Clinical Negligence: Who Pays The Price?

When the nerve roots below the termination of the spinal cord are compressed from physical trauma, infection and inflammation, a prolapsed (slipped) disc, or tumour, the patient must be referred urgently to hospital for surgical decompression. Even short delays can result in permanent loss of function and disability, which is why it is so important for GPs to know and act upon the danger signs. These are known as red flag symptoms and include:

  • Pain on both sides radiating below the knee
  • Lower limb numbness or weakness
  • Numbness on either side of the buttocks and saddle area
  • Disturbance of bowel function
  • Disturbance of bladder function, such as difficulty passing urine, poor stream or loss of sensation
  • Erectile dysfunction
  • Loss of anal tone or impaired sensation on rectal examination

Recognition of the signs of CES can be complicated where a patient has a pre-existing back condition, so careful examination and questioning must be undertaken to establish the cause of the pain. If red flag symptoms are identified, the patient’s GP should contact the hospital’s neurosurgical or orthopaedic specialist for immediate advice or arrange for the patient’s emergency admission to hospital.

Boyes Turner’s medical negligence specialists secure maximum value compensation awards for clients disabled through negligent delay in diagnosis and treatment of cauda equina syndrome.

Settlements have included:

Medical Defence Union warns GPs - Cauda equina is a medical emergency

One of the UK’s leading medical defence organisations, the Medical Defence Union (MDU), which represents and indemnifies doctors, has warned GPs about the importance of prompt diagnosis of cauda equina syndrome (CES). Even short delays in recognising the red flag symptoms of this serious, neurological condition can result in permanent disability. Since 2005 the MDU has paid out £8 million on behalf of doctors as compensation to patients disabled by undiagnosed CES.

Cauda equina syndrome occurs when the nerve roots below the termination of the spinal cord are compressed. Common  causes of nerve root compression are disc prolapse (slipped disc), physical trauma to the area, tumour, infection and inflammation. In its early stages the condition can be difficult to diagnose, particularly if the patient’s main complaint is lower back pain. However, careful listening and direct questioning about other related symptoms should reveal symptoms and signs which differentiate this medical emergency from other less dangerous conditions. When a diagnosis of cauda equina is suspected the patient must be referred to hospital urgently so that surgical decompression can take place before the patient suffers permanent loss of function.

In their warning, the MDU gave advice to GPs on ways to avoid delays in diagnosis of cauda equina syndrome. GPs were reminded to:

  • Carry out a full examination of the patient to establish the cause of their back pain and record the examination in the medical notes

Consider red flag symptoms:

  • Pain radiating below the knee bilaterally (on both sides)
  • Lower limb numbness or weakness
  • Numbness on either side of the buttocks and saddle area
  • Disturbance of bowel function
  • Disturbance of bladder function, such as difficulty passing urine, poor stream or loss of sensation
  • Erectile dysfunction
  • Loss of anal tone or impaired sensation on rectal examination
  • If red flag symptoms are found, the GP should call the hospital orthopaedic or neurosurgical specialist for immediate advice. In their absence, they should arrange for the patient’s admission to hospital via the emergency department
  • Patients with back pain should be given ‘safety netting’ advice, including warning the patient of CES symptoms to look out for and the importance of seeking urgent medical help if these symptoms should appear
  • GPs should make a record in the medical notes to show that they have considered cauda equina syndrome and have given appropriate advice

Delay in diagnosis or failure to arrange emergency surgical treatment can result in the patient suffering permanent disability.

At Boyes Turner, our experienced and specialist medical negligence lawyers have secured compensation awards for clients with cauda equina syndrome. Despite presenting to their doctors with red flag symptoms their CES diagnosis and treatment was delayed. As a result they now have:

With GPs under increasingly greater pressure we welcome the MDU’s timely reminder that cauda equina is a medical emergency requiring prompt diagnosis and urgent hospital referral.

A smear test lasts 5 minutes - the impact of cervical cancer lasts a lifetime

The aftermath of cervical cancer can be debilitating.

Our clients, cervical cancer survivors beat cancer but continue to live with the life-changing side effects of the disease and the treatment. Our client, Josie explains the physical and emotional effects she experienced during and after her cervical cancer journey.A smear test lasts 5 Minutes - Cervical Smear awareness week

In Josie’s words, “life will never be the same after a cancer diagnosis.”

We understand just how devastating a diagnosis of cervical cancer can be and the effect it can have on your life, because of clients like Josie. This is why smear tests are essential and why it’s important to us to support Jo’s Cervical Cancer Trust during Cervical Screening Awareness week (13-19 June 2016). We want to help spread the message – screening can reduce the risk of cervical cancer developing, avoiding the sometimes permanent and disabling side effects of cervical cancer.

The Trust, a charity committed to supporting women affected by cervical cancer & abnormalities can help with support or information about cervical screening – click here for further information.

Cauda equina syndrome - Life after diagnosis (PART ONE)

I am a medical negligence solicitor and have been working on cases involving cauda equina syndrome for the last 6 years. I have dealt with a number of cases involving delays in diagnosis and treatment of the condition and seen first-hand the impact that it can have on an individual, and how it can affect every facet of their life.

More recently I have become acutely aware of the poor follow up support and treatment available to people who suffer with cauda equina. The available support and treatment options as limited when compared to those available following, for example, a spinal injury or an amputation. They are often afforded specialist treatment in specialist centres, whether that be in the form of general rehab, physiotherapy, occupational therapy or prosthetics.

For people with cauda equina syndrome, no such support network exists.

This was highlighted recently again to me, when I visited a client who has been through a diagnosis of cauda equina, and is now having to learn to cope with the symptoms she has been left with, after there was a delay in diagnosing and treating her condition.

In the first of this two part series on cauda equina I will discuss what cauda equina is, how it is diagnosed and what treatment is available for it.  I will also be talking about the type of symptoms you can be left and how these affect everyday life.

What is cauda equina syndrome?

Cauda equina syndrome (sometimes known by the abbreviated letters CES) is a term that you will likely never come across – unless you become affected by it, or you know somebody who has been.

Cauda equina is a rare neurological condition, where the nerves in the spinal column are compressed. The nerves that are affected by the compression are those that control bladder and bowel function and sexual function as well. The nerves are collectively known as the cauda equina nerves because they hang down from the spinal column and resemble a horse’s tale.

Cauda equina claims - Boyes Turner solicitors

What are the symptoms of cauda equina?

Symptoms of cauda equina syndrome include:

  • Lower back pain
  • Radiating pain from other areas of the body
  • Numbness and/or weakness and/or pain in the legs
  • Loss of sensation in the buttock and pelvic region
  • Bowel or bladder dysfunction
  • Sexual dysfunction

Cauda equina syndrome can be difficult to diagnose because not all of the above symptoms will be experienced. The symptoms can be of varying degrees and over different timescales.

Cauda equina syndrome is a rare condition but doctors should be aware of the “red flag” symptoms listed here and must ensure that there are no significant delays in providing medical treatment. An early diagnosis of cauda equina syndrome is vital.

Cauda equina treatment and recovery

It is becoming more apparent to me, with each new cauda equina medical negligence case that I am approached about, that the level of after care and support available to people suffering with cauda equina is considerably lacking, given the significant impact this can have on a person’s everyday life.

Cauda equina sufferers require urgent and complex surgery to remove the pressure on the spinal nerves. Often, until then, they might have only suffered with what is colloquially known as “mechanical back pain” or sciatica. Urgent neurosurgery is a daunting prospect for anyone, but especially someone who has been in such sudden and extreme pain.

Once the neurosurgery has taken place and the recovery is underway, the patient is discharged from hospital. Unfortunately, one of the complicating factors of the syndrome is that, if a certain amount of time has passed since the onset of the compression of the nerves, only limited function may be restored with surgery.

In these circumstances there is unlikely to be much improvement in the bladder and bowel function. Sometimes a small amount of recovery and restoration of function can occur, but this is often minimal.  People often don’t appreciate that their ongoing symptoms are actually as a result of the nerve damage that has occurred.  People don’t understand the full catalogue of their symptoms.

Ongoing pain and incontinence

There is usually some immediate relief of the excruciating back pain symptoms following surgery. However patients are often left with some degree of ongoing, low level, back pain as well. So after undergoing major spinal surgery, an individual may not really notice that much improvement in their symptoms overall and that can be difficult to come to terms with in itself.

Typically, people who have suffered with cauda equina syndrome are left with a urinary urgency or even full incontinence, a difficulty to distinguish between flatulence and the need to pass a bowel motion, and even more concerning, symptoms of numbness in the saddle or groin area.

Not symptoms that people generally want to talk about!

These symptoms in isolation may not seem to present too much of a problem to you and I.  But think through the practicalities. Think about having to perform intermittent self-catheterisation. Think about having to manually evacuate your bowel.

These are all issues that we generally shy away from discussing and don’t form the topic of polite conversation. Unfortunately people with cauda equina syndrome are dealing with these difficulties every day, and the support available to them is woefully inadequate.

Why is a quick diagnosis so important?

Time is never more of the essence than in a case of cauda equina syndrome. The condition can progress at different speeds in different people and it is possible to have a partial cauda equina syndrome or full cauda equina.

If you are diagnosed while you still have only a partial cauda equina lesion, you stand a good chance of making a full neurological recovery. This means the urinary and bowel symptoms are likely to be less severe and thus easier to manage in everyday life.

However, with every passing hour without treatment, more and more damage is being done to the compressed nerves in the spinal column. Once that damage reaches a certain point, it becomes irreversible. Once a patient reaches this point, it is categorised as complete cauda equina. Sadly this means that the symptoms at the time of diagnosis and surgery are not likely to resolve or spontaneously improve after surgery. Surgery is still however required to alleviate the compression in the spine.

Cauda equina diagnosis usually involves an MRI scan, so that the level of the compression in the spine can be identified. Surgery is usually carried out as an emergency, by either a spinal surgeon or a neurosurgeon.

In the second part of our cauda equina series I will discuss the impact of that the symptoms of cauda equina can have upon everyday life.

Coming to terms with cauda equina - A client story

We recently recovered £400,000 in medical negligence compensation for our client, Alice*, following a delay in diagnosis of her cauda equina syndrome which has left her with persistent and permanent urinary and faecal incontinence, a permanent loss of sexual sensation, altered sensation in the left perianal region, left gluteal area and the back of her left thigh, and a psychological reaction to her injuries.

Following the successful conclusion of her claim Alice discussed her experience of the negligence claims process.

“After I was diagnosed with cauda equina syndrome, I went online to try to find out more about the condition. I was quite overwhelmed by the amount of information available online but there was a complete absence of local support. 

I initially contacted a firm of solicitors who were based in Yorkshire, and who appeared to have a lot of experience with cases involving cauda equina syndrome from the content on their website. However, when I actually contacted the solicitors, they were very cold and didn’t appear to understand the condition very well at all. It very much concerned me that they were based in Yorkshire and I really wanted to look for a local firm of solicitors.

A friend of mine referred me to Boyes Turner. Someone she knew had instructed Boyes Turner in relation to a birth injury claim, and she suggested that I speak to one of the specialist medical negligence solicitors there about making a cauda equina negligence claim.

I spoke to Julie Marsh first, and she was instantly understanding of my condition and the warmth of her response and her reassuring nature immediately put me at ease. 

Everything else I had seen online about bringing a claim felt gimmicky and disconcerting but I was reassured as soon as I spoke to Julie.  When I had the chance to meet her she was very down-to-earth, and I never felt awkward discussing immensely personal issues with her.

Being diagnosed with cauda equina syndrome was very scary, and every day I faced a new challenge. It was so important to me that I felt I could ask Julie anything about the negligence claims process, or what would happen next, and I knew she would always make the time to listen to my concerns and reassure me that the case was progressing as it should. It was one less thing I needed to worry about.

I think I had this glamorous idea of the legal process which I must have got from watching TV.  I didn’t have any idea until I spoken to Julie how long the process could be, or the steps involved.

My parents were quite concerned that I was pursuing a medical negligence claim, and didn’t feel that I really needed to. They thought I just had a bad back. It was when my treating surgeon at Royal Berkshire Hospital said that I should have been operated on six weeks before he saw me that I began to feel angry about the delay in diagnosis of my cauda equina syndrome. It was the trigger for me to seek legal advice.

I found it very frustrating to think that nobody had taken me seriously, and my GP and the hospital had ignored the symptoms that I had reported to them. I am not the type of person who wants to make a fuss and I am not sure if I would have decided to pursue a negligence claim if I hadn’t been supported by a local solicitor. I didn’t want to talk to somebody who was remote from the entire situation or from me.

The initial part of the claim was quite easy, talking about what had happened with Julie and getting updates about the obtaining of my medical records. It wasn’t until I saw the reports of the medical experts that I realised how complicated the case was. 

I knew that the claim wasn’t going to be a quick process but Julie always kept me up to date as matters progressed, and I felt I always knew what stage of the process I was at. I was terrified about the possibility of going to Court, but Julie explained the process thoroughly and I felt entirely supported by our Barrister, Clodagh Bradley.

There was a delay in receiving the response to my case from both the GP and the hospital and it got really frustrating waiting to hear what they were going to say. It meant I was always replaying what had happened in my head, and I was always worried that I was forgetting some vital piece of information. It was difficult because I was still trying to juggle work and life and my ongoing symptoms at the same time.

I was regularly involved in meetings with our Barrister about the case. It was terrifying the first time I went to see her because I had to talk to somebody else about very personal issues. She was very thorough and approachable though and I was grateful that she was on our side.

I remember the telephone call from Julie telling me that the hospital had formally admitted the mistakes that they made in my treatment. It wasn’t until then that I had allowed myself to even think about compensation and what a settlement might mean in terms of getting my life back. I was just so relieved that they had admitted it was their fault.

Julie and her colleagues carefully counselled me about the next steps of the case, even though liability had been admitted, and I had to understand that there was still a possibility I would have to go to Court. I still had to attend a number of meetings with medical experts, and I found that very tough, having to regularly talk about my ongoing symptoms.

When I received the first offer in settlement of the claim, it was my knee jerk reaction just to want to take it and run away from the whole process. I was ready to see an end to it but Julie helped me understand that we needed to talk this through with the Barrister. After a detailed discussion I was advised that further negotiations should take place to try to achieve an increase in the level of compensation that I would be awarded.

I am so relieved that the matter has settled now, and that I didn’t need to go to Court, but strangely it feels like a bit of a void and I keep expecting post to drop through the door from Julie.

No amount of money will change the symptoms that I have or the difficulties that I face managing them now and will have in the future. However the compensation that I have received means that I have some financial security for the future, and that I can provide for my daughter. I am still trying to come to terms with what has happened and the challenges I face day to day, but now I can do so without the added financial pressure.  

I am so glad that I found Boyes Turner and Julie Marsh to bring the claim on my behalf”.

Delay in diagnosis of cauda equina syndrome claims

Boyes Turner’s specialist cauda equina claim solicitors are currently investigating five different claims for clients who experienced a delay in diagnosis of cauda equina syndrome.  The clients are of different ages, background and locations.

Each of these clients suffered a delay in receiving surgical treatment because of a delay in the initial diagnosis by their GP and/or hospital doctor.

The allegations against the doctors range from:

  • Failure to recognise the symptoms of cauda equina syndrome.
  • Failure to give appropriate advice and warning signs of progression of the symptoms to the client.
  • Failure to inform the patient to attend an accident and emergency department at hospital if specific symptoms arise i.e. numbness.
  • Failure to refer the client for emergency treatment.

Our clients now suffer with a range of varying life long disabilities.  The common difficulties however include bowel and bladder difficulties including incontinence as well as back pain, difficulty walking, sexual dysfunction and numbness.

We are also working with our clients to deal with the emotional side of their difficulties and helping them to overcome this whether by answering their questions as part of the medical negligence investigation or once at the point of valuing the case, including a claim for psychological treatment from a specialist therapist and/or psychiatrist.

£750,000 compensation awarded after delay in diagnosis of cauda equina syndrome

A man has reportedly recently received £750k for the failure to perform proper investigations to identify a disc prolapse, resulting in cauda equina syndrome.  He now suffers from long term neurological impairment in terms of mobility, incontinence, sexual dysfunction and neuropathic pain.

The man initially experienced pain in his back, weakness in the right leg and an odd sensation in the saddle area. He also experienced a feeling of wanting to urinate but difficulty actually doing so.

The man attended hospital immediately via ambulance following advice from NHS Direct.  An x-ray was performed at hospital and reported as normal. A junior doctor discharged the man and no advice was given other than to return if the symptoms did not improve. No other investigations were carried out.

The following day, the symptoms worsened including lack of sensation in both bowel and bladder function. He called an ambulance and was taken to hospital. An MRI scan was requested which showed the prolapse. Decompression surgery was subsequently carried out.

The hospital admitted they were negligent in failing to suspect cauda equina syndrome and do appropriate investigations. The hospital admitted that if surgery had been undertaken urgently, the man would have not been left with neurological dysfunction and would have had normal bladder, bowel and sexual function.

Sadly, the man was unable to return to full time employment and had difficulties undertaking daily tasks such as driving, socialising and general household tasks. He required assistance from his family. When outdoors, he was reliant on a walking stick. The man also suffered with depression as a result of his long term difficulties.

“It is astonishing that despite this man’s “red flag” symptoms, the doctor at the hospital did not suspect cauda equina syndrome. Red flag symptoms such as numbness, weakness in legs and bladder problems should always warrant urgent further investigation including an MRI scan. Early diagnosis is essential! Unfortunately for this man, due to medical negligence, the diagnosis and surgery was too late to prevent permanent nerve damage.”

Delay in diagnosis of cauda equina - £98,000 compensation awarded

On 7 November 2008 Nigel, aged 50, was required to move heavy boxes at work.  Whilst doing so, he experienced discomfort in his back, and it developed into significant pain.  Later he developed weakness in his right leg and strange sensations in the saddle area with the feeling that he wanted to go to the toilet all of the time.  However when Nigel tried to pass urine, it was difficult to do so.

Nigel’s symptoms persisted throughout that evening and the pain increased, and he was advised that he was to be assessed on an emergency basis. An ambulance was arranged to attend his home address. Correctly, the NHS Direct operator suspected a cauda equina injury because of the problems passing urine.

The ambulance crew arrived to find Nigel lying on the floor. He was unable to sit up. He was taken to a hospital of North West London Hospitals NHS Trust, and assessed by a triage nurse.

Nigel was subsequently assessed by a junior doctor who requested an x-ray. This was performed at 15:25, 2½ hours after his arrival at hospital. It was reported as normal. The junior doctor advised Nigel that there was no evidence of a cord compression, and he was ready to be discharged. He was advised to return if his symptoms did not improve, but was given no additional advice.

On 9 November, Nigel was sent home, and his symptoms persisted throughout the day.

When Nigel woke on the morning of 10 November, the pain was more intense, his right leg and foot were much weaker, and he had no sensation of his bowel and bladder.  He called an ambulance, and arrived at hospital at 11am.  An MRI scan was undertaken at 16:00 and reported a disc prolapsedat L4-L5, which was causing a severe compression of the cauda equina nerve.

The hospital was unable to operate on Nigel on an emergency basis, and he was transferred to another hospital where he underwent disc decompression surgery the next day.

Nigel alleged that the first hospital was negligent in failing to suspect cauda equina syndrome when he presented on 8 November, and failing to undertake appropriate investigations to investigate a disc prolapsed.

The hospital trust admitted liability and confirmed that, had Nigel undergone surgical decompression of his cauda equina on either 8 or 9 November, he would have had normal bladder, bowel and sexual function, together with normal neurological function.

Nigel was affected significantly, both physically and psychologically. He relied on walking sticks when mobilising out of the house, and generally moved in a slow and stiff manner. Moving or changing position triggered Nigel’s pain.

Nigel has continued to experience numbness in the saddle area, down the back of his legs and on the side of his feet and heels.  He also had shooting pain in his saddle area and hypersensitivity in his left foot.

Nigel has permanent bladder, bowel and sexual dysfunction. He was unable to pass urine or empty his bladder normally. He is dependent on self intermittent catheterisation which he performs four times a day.

Nigel suffered from a loss of sensation in his penis and erectile dysfunction.  He lost the ability to perceive the need to open his bowels, and suffered faecal incontinence.

Nigel experienced a major depressive episode of between 2-3½ years after the injury. He was a risk of future depressive episodes.

The claim was settled on the basis of an award for £98,000 for his pain, suffering and loss of amenity.  He was afforded future accommodation costs to allow him to move to a more suitable property, in the sum of £390,000.  He was also awarded a sum of £120,000 for future care costs, £10,000 for future transport costs, and £27,000 for future therapy costs. In addition he received a future loss of earnings award at £17,780, a future aids and equipment award at £28,500, and additional future medical treatment costs at £33,000. His past losses totalled £42,000.

Claim against GP for failure to diagnose a man's cauda equina syndrome

The Boyes Turner medical negligence team secured a High Court judgement for a 40 year old man suffering from cauda equina syndrome (CES). The claim was brought against a GP following a failure by him in 2007 to diagnose and refer for this rare but devastating condition which presents with severe low back pain, sciatica, saddle and genital sensory deficit and bladder, bowel and sexual dysfunction. 

After High Court proceedings were started, admissions were made by the GP’s solicitors about medical negligence but the case was defended on the basis that by the time the GP was negligent the damage had been done – i.e. that he had been negligent but no injury had resulted from that negligence.

The case therefore proceeded through the Court timetable with a trial listed for July 2010 until in January 2010 the GP through his solicitors conceded that the damage would have been avoided enabling Judgment to be entered against him.

The injuries to our client are very significant and the case will now move on to valuation. It is likely to be worth a high six figure sum.

A letter of apology was received from the GP.

The service provided was first class. You were understanding, caring and professional

David Froud

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