Back pain became cauda equina

The scene

The patient had been seen six days previously by the MDU member's partner. She noted low back pain radiating into the left leg, recorded that there was no problem with micturition and prescribed painkillers. Four days later, the patient called the out of hours service complaining of severe pain. It was again noted that he had no problems passing urine.

Later the same day, the patient came to see our member in surgery. The GP noted that the patient had severe pain in his left leg and some numbness. He recorded that the patient was experiencing no problems with passing urine or opening his bowels. On examination, the GP found and noted some reduction in straight leg raising on the left side. He prescribed painkillers and asked the patient to return in a week, or earlier if his condition deteriorated.

Three days later, the patient called the GP's partner to his home. She found that he had numbness in the buttock and perineum and was incontinent of urine. She admitted him to hospital urgently and he underwent L5/S1 discectomy and nerve root decompression two days later. Unfortunately, the patient had persistent numbness in his legs and buttock and did not regain continence.

Several months later, the GP received a letter of claim from the patient's solicitor alleging that the patient had complained to the GP member of numbness when passing urine and that the GP failed to record this. The claimant also alleged that it was negligent not to have performed a rectal examination to assess anal tone at that time, and that our member failed to warn the patient that his condition could be serious and that he should go to hospital at once if his condition worsened.
 
The letter concluded with the allegation that if our member had adequately examined the patient, he would have noted reduced anal tone and would have referred the patient to hospital. He would have had an urgent MRI scan and would have proceeded to discectomy within 24 hours, avoiding all of his long-term problems.

The outcome

The MDU instructed two experts to consider the claimant's case. The first expert was an independent GP who considered the member's management. The GP expert noted that the out of hours doctor had recorded that the claimant had had no problems with passing urine about six hours before he saw our member – this supported our member's findings. The expert noted that our member had made a full entry of positive and negative findings, including a record that the patient did not have problems with his bowels.

The GP expert therefore did not feel that a rectal examination was indicated. Although the member had not recorded what advice he gave, he stated that his usual practice in such cases was to advise the patient to return or call again if the pain was worse or should problems develop in the bladder or bowels. The expert concluded that the GP's management was reasonable.
 
The MDU instructed a neurosurgeon to consider whether the outcome could have been improved if the patient had been managed differently. The expert commented that if our member had referred the patient to hospital with the symptoms and clinical findings that the member and the out of hours doctor described, it was most likely that the patient would have been seen in A&E and discharged.

Our expert commented on the difficulty of predicting the onset and clinical evolution of cauda equina syndrome. He concluded that, on the balance of probabilities, the central disc prolapse occurred the day after the patient was seen by our member. He felt, therefore, that the damage was irreversible by the time the patient sought further medical help and he was not critical of the hospital for any delay in proceeding to surgery.
 
In view of the supportive expert opinion, the MDU served a letter of response on behalf of our member, summarising the findings of its experts and denying the member's liability. Solicitors acting for the patient later confirmed that they had closed their file.

Cauda equina is a rare but serious complication of degenerative spinal disease. Most GPs see many patients with low back pain and sciatica but rarely see such serious complications. The GP member made a full record of his negative findings – this assisted our expert in concluding that his management was of an acceptable standard. It was also helpful that his findings concurred with those of the out of hours doctor who had seen the patient such a short time before our member.

This page was correct at publication on 16/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.