This month, Lawyer Monthly hears from Dr. Charles E Rawlings, a neurosurgeon and expert witness as well as a nationally recognised plaintiff’s medical malpractice attorney. He has written extensively on the condition and treated many patients with cauda equina syndrome. Below, he explores why it is important to diagnose and treat cauda equina syndrome early – and the numerous ways in which failure to do so may constitute medical negligence.
Cauda equina syndrome (CES) is a severe neurological disorder that appears to have been first described by Mixter and Barr in 1934. The disorder can be caused by any entity exerting pressure upon the cauda equina including hematomas, tumours, infections or fractures. More importantly, however, between two and six percent of lumbar disk herniations result in cauda equina syndrome. As a consequence, if a patient suffers from cauda equina syndrome, the cauda equina compression is most likely secondary to a disk herniation.
Most authors define cauda equina syndrome as a neurological disorder characterised by clinical features of low back pain, bilateral or unilateral leg pain (radiculopathy) saddle anesthesia (reduced sensation in the perineum, buttocks, anus, groin, and upper thighs), motor weakness, sensory deficit, and bladder or bowel incontinence.
Although patients with cauda equina syndrome may present to their family practitioners or even specialists such as neurosurgeons or orthopedists, a far greater number present to the emergency department for initial evaluation and treatment. Generally, certain acts or omissions by the emergency department staff can lead to medical negligence.
Such acts or omissions include failure of the nursing staff to document and communicate a patient’s symptoms, signs or progression thereof; failure of a physician to obtain an accurate, thorough history accompanied by a complete physical examination, including a rectal examination; failure of the physician to recognise cauda equina syndrome and failure to obtain emergency imaging, consultation, or referral once a patient is diagnosed with cauda equina syndrome.
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The most important aspect of cauda equina syndrome is the need for early diagnosis and early referral leading to surgical treatment within 48 hours of the onset of symptoms. Detailed below are the symptoms and a brief overview of appropriate treatments.
Cauda equina syndrome, however, is a neurological entity caused by pressure upon the cauda equina generally due to a ruptured lumbar intervertebral disc. Cauda equina syndrome is characterised by low back pain, bilateral or unilateral lumbar radiculopathy, motor, and sensory deficits as well as bladder or bowel dysfunction. Most authors define cauda equina syndrome only when bladder dysfunction is present in the patient. In other words, cauda equina syndrome does not exist and cannot be diagnosed in the absence of bladder dysfunction. With regard to treatment, most ruptured lumbar disks can be treated conservatively, either successfully or on an interim basis until surgery becomes necessary.
Cauda equina syndrome is a true surgical emergency and is the only true absolute indication for surgical treatment of a patient with a ruptured lumbar disc. Most authors recommend surgery as soon as possible, with studies indicating much poorer results if the surgery takes place 48 hours or more following the onset of the symptoms.
With regards to the medico-legal implications of cauda equina syndrome, Shapiro notes: “Serious legal implications about emergency room and doctor office management of this problem exist”. To avoid these “serious legal implications”, practitioners must continue to view cauda equina syndrome as a true surgical emergency that requires both emergent diagnostic and treatment actions. Any patient with urinary dysfunction must be studied on an emergent basis, particularly if the patient has suffered an acute change coupled with other discogenic symptoms. The physician must be aware of the condition and must have the skills to diagnose the entity and order an MRI to evaluate the cauda equina and lumbar spine.
Cauda equina syndrome is a true surgical emergency and is the only true absolute indication for surgical treatment of a patient with a ruptured lumbar disc.
Moreover, the physician must recognise that cauda equina syndrome is a surgical emergency requiring immediate referral to or consultation with a qualified spine surgeon. The patient cannot be allowed to linger without studies or consultation. This caveat is especially true with regard to evenings, weekends, or holidays. A patient with acute cauda equina syndrome cannot be treated as a routine pain patient and to do so is medical negligence.
Upon the finding of medical negligence in the diagnosis and treatment of cauda equina syndrome, the victim should be compensated for any residual neurological deficits, permanent paralysis, pain and suffering, lost wages, emergency transportation expenses, current and future medical treatments and costs associated with the victim’s rehabilitation or other necessary therapies or counselling.
If someone believes they have suffered cauda equina syndrome, or damages therefrom, as a result of medical malpractice, deficits in treatment, improper treatments, or delays in treatment, they must first gather all their pertinent medical records. In addition, they must gather all their medical expenses, lost wage documentation (such as W-2s or tax returns), and all associated expenses pertinent to their condition. They should then immediately call The Rawlings Law Firm for further consultation.
Charles E Rawlings, MD
301 N Main St Suite 1020, Winston-Salem, NC 27101, USA
Tel: +1 336-725-6444
E: assistant@rawlingslawfirm.com
Dr. Charles E Rawlings is a Board-certified neurosurgeon who was actively involved in medical malpractice litigation as a consultant, case reviewer, and expert witness for 14 years prior to becoming an attorney. Today, he draws upon many years of expert practice in both the medical and legal spheres to bring his clients’ cases to a successful conclusion. Dr. Rawlings is recognised by Super Lawyers, and as a Top 100 attorney by The National Trial Lawyers and has received numerous other accolades. He has been admitted to the Bar in North Carolina, South Carolina, New Jersey, Texas, and Pennsylvania. He has also successfully managed multiple malpractice claims with regard to cauda equina syndrome.
