Cauda equina is the source of some of the highest value claims against Medical Protection members. This case report highlights how important it is to keep an eye out for the ‘red flags’ associated with the syndrome.

When Mrs C, a keen golfer in her early forties, began to experience constant pain in her lower back, she consulted a GP at her local surgery. Dr P took a history of slow onset of pain with restricted mobility. He did not examine her, but prescribed an NSAID and advised Mrs C to return in two weeks if there was no improvement.

Over the following three months, Mrs C made five more visits to the surgery with the same complaint, seeing a different doctor on each occasion. On her fourth visit, when she consulted Dr L, she complained of numbness in her perineum and that her back pain was now radiating down both her legs. Dr L recorded these symptoms in her notes, but did not examine Mrs C. Her notes read: “lumbar pain for 10/52 now, getting worse. Saddle anaesthesia. Refer physio”.

Dr L did refer Mrs C, but as there was a long waiting list for physiotherapy, Mrs C’s first appointment was to be in six months’ time.

In the meantime, Mrs C was becoming increasingly distressed as her symptoms worsened; she returned to the surgery, this time consulting Dr V. Again, saddle anaesthesia and bilateral sciatica were noted, but Dr V merely prescribed stronger analgesia and suggested that Mrs C perform daily gentle exercises. His notes mentioned that Mrs C was “highly strung”, so he may have thought that she was overstating her symptoms.

Mrs C returned to the surgery two days later and was seen by Dr G. This time she had a new and distressing symptom to add; she had been incontinent of urine. Dr G, looking through her past medical history, observed that Mrs C’s pelvic floor had probably been weakened by the five vaginal deliveries she had had during her twenties and thirties. He instructed her in carrying out pelvic floor exercises and arranged a gynaecology referral for assessment.

That evening Mrs C’s back pain intensified to the extent that she was unable to walk. Her husband called for an ambulance and she was taken to the local A&E department. An MRI scan confirmed a massive central disc protrusion at L4/L5 and surgery was carried out as a matter of urgency to relieve the pressure on the cauda equina. Unfortunately, the discectomy did not have the desired effect.

Mrs C was left with permanent neurological damage, unable to walk and doubly incontinent. Mrs C brought a claim against her GP practice, alleging that the signs of cauda equina syndrome had been apparent during her consultations and that the GPs’ failure to diagnose her condition had deprived her of timely treatment and the chance of a full recovery.

Expert opinion

In the opinion of GP experts, Dr P could be criticised for not examining Mrs C, but his treatment and advice were otherwise reasonable in the circumstances. They reserved their detailed criticism for Dr L, Dr V and Dr G who, they felt, had all delivered substandard care. Mrs C had presented to each of them with clear warning signs of cauda equina syndrome and they should have referred her to hospital as a matter of urgency. Moreover, none of them had examined Mrs C to determine the extent of her problems.

On causation, an expert in neurosurgery concluded that Mrs C would have been left with “little or no” permanent neurological damage if she had been operated on within 48 hours of seeing Dr L. He thought that by the time she saw Dr V some permanent impairment had probably already occurred, but that she would have regained more use of her legs if intervention had taken place at that time.

The case was settled out of court for a substantial sum.  

Red flags

1. Bilateral or unilateral sciatica
2. Bladder or bowel dysfunction
3. Anaesthesia or paraesthesia in perineal region or buttocks
4. Significant lower limb weakness
5. Gait disturbance
6. Sexual dysfunction.

Learning points

• Although lower back pain is commonplace, it is still important that you take and record a proper history and examine the patient for signs of neurological impairment.
• Continuity of care can be difficult when a patient consult a series of different doctors about an ongoing complaint. You should therefore refer to earlier entries in the patient’s record especially when seeing someone for the first time.
• Cauda equina syndrome often has a chronic onset, so be alert to this when seeing patients making repeated visits for unresolved lower back pain.
• Familiarise yourself with the ‘red flags’ associated with cauda equina syndrome and refer the patient urgently if these are apparent in association with severe low back pain.