Delay in diagnosis of cauda equina syndrome (2)

The patient attended accident and emergency. He had suffered severe discomfort after lifting a heavy weight two days before. The following day he had been treated by an osteopath and then felt diminished sensation in his genitalia during sexual intercourse. He complained of pain and weakness in his legs, numbness in his buttocks and penis, and an inability to pass urine. An examination revealed diminished fine sensations in the perineal area and his right leg. He was prescribed analgesics, told to rest and discharged.

He phoned his GP two days later, complaining of continued back pain and weakness in his legs, which made it difficult for him to walk. The GP was about to start surgery and felt unable to make a home visit. She knew the patient had a history of back pain and thought the symptoms were consistent with sciatic irritation. She prescribed a stronger analgesic.

Three days later, he was visited at home by a second GP, to whom he complained of back pain and pins and needles down his legs, constipation and an inability to pass urine standing. The GP's initial impression was of a prolapsed lumbar disc. He told the patient he would make an urgent orthopaedic referral for him to have traction.

The patient was taken to surgery by a relative the next day. He was seen by the second GP who noted he was constipated, had urinary incontinence, complete loss of sphincter tone and sensory loss in both legs.

He was admitted to hospital where investigations revealed a massive central prolapsed disc at L4/5. Surgeons performed a laminectomy and excised disc material.

Negligence alleged

The patient alleged that a delay in diagnosis of cauda equina syndrome had caused him considerable residual problems, including bladder and bowel disorder, sexual dysfunction and weakness of the right leg. He accused the health authority and the two GPs of negligence on several counts. He alleged doctors at the hospital had failed to examine him adequately on his first visit and to observe bladder distension. They had also failed to ask him about his bladder, bowel and sexual function. The two GPs had allegedly both failed to heed and act on information sent to them by the hospital. They had failed to adequately examine the patient and to refer him immediately to hospital for appropriate specialist treatment.

Expert opinion

The experts agreed that all three defendants proposed to admit liability. (The first GP was represented by the MDU and the second by another medical defence organisation). However, the various expert reports gave different views on causation: would there have been a better result with an earlier operation? There was agreement that, in some cases of cauda equina syndrome, the initial damage is so serious that there is no difference at whatever point the operation is performed. One expert felt this was the case here. Others argued that the patient's condition deteriorated over time. One pointed to the sequestered portion of the disc which was found during the operation and said it would have taken about 72 hours for the disc to get like this.

Outcome of claim

The case went to trial, where the judge accepted the evidence that the patient would have been significantly better off if he had been operated on when he first attended hospital. He awarded damages of more than £250,000, which were shared among the two GPs and the trust. The MDU paid 10 per cent on behalf of our member.

This page was correct at publication on 01/01/2002. 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.