Cauda Equine Syndrome: Takeaways from Lawsuits

Back pain is one of the most common complaints in the emergency department. The vast majority of complaints are benign, musculoskeletal in nature, and do not warrant emergent imaging or evaluation. However, a few entities can be both life and limb-threatening if not diagnosed and treated expeditiously from the ER. This syndrome involves compression of the spinal cord, leading to the well-described “Cauda Equina” syndrome.

What is Cauda Equina Syndrome?

Cauda equina, which means “tail of a horse” in Latin, is a syndrome where a bundle of nerves at the base of the spinal cord can become compressed, leading to potentially irreversible neurological deficits, loss of mobility, and paralysis. Common presenting symptoms include back pain that radiates down the legs, bladder and/or bowel incontinence, saddle anesthesia (numbness in the groin), sexual dysfunction, and leg weakness. While Cauda Equina Syndrome (CES) can present in several ways, there are recurrent common themes in malpractice claims that have been brought forward.

Delay in Diagnosis

MRI is the gold standard imaging test to diagnose Cauda Equina Syndrome. This can sometimes be difficult if there is no MRI capability in the hospital or there is no after-hours MRI staff to perform the test emergently. A 26-year-old presented to the ER with low back pain radiating down his legs. An MRI was not available, and the ER physician ordered a CT scan of the lumbar spine which showed possible iliopsoas muscle bases. The patient was admitted to the hospital overnight, and his condition deteriorated quickly to lower extremity paralysis. He was finally transferred to another hospital the next day where an MRI revealed an epidural abscess over the spinal cord. He remained quadriplegic and required long-term 24-hour skilled care.

Takeaway: If a physician suspects Cauda Equina Syndrome, MRI is the test of choice to make the diagnosis. Because Cauda Equina Syndrome is time-sensitive, patients should be emergency transferred to a facility where there is MRI capability if the diagnosis is suspected and unable to be performed at the facility where the patient presents.

Surgical Delay

John Doe presented to the Emergency Room with back pain. He was diagnosed with a herniated disc, and outpatient laminectomy was performed to relieve pressure on the nerve. Post-operatively he developed a blood clot (hematoma), but the hematoma was not evacuated for several days, leading John Doe to develop CES and permanent deficits of foot drop and incontinence:

Takeaway: Postoperative surgical hematomas must be evacuated within 24-48 hours to avoid the risk of CES and permanent neurologic injury.

Systems Issues

A 31-year-old presented to the emergency department with back pain radiating down the legs with bladder incontinence. An MRI was ordered by the ER physician and the MRI order was communicated to the radiology department. The MRI was available for use, but not performed for over 24 hours. During this time the patient deteriorated and developed leg weakness and numbness, ultimately sustaining permanent neurologic deficit. The hospital system and radiology group were named in the lawsuit for failure to perform the MRI expeditiously.

Takeaway: Communication protocols between the emergency department and radiology departments must be in place to ensure MRIs that are ordered on an emergent basis are done expeditiously.

While the incidence of Cauda equina syndrome is rare, it is one of the very back-related medical emergencies that present to the emergency department that can result in disastrous consequences if there are delays. Lawsuits most often involve time-sensitive breaches in the standard of care. Failure to diagnose timely, failure to order imaging timely, and failure to operate in a timely manner.

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