Medical Malpractice Insights: Cauda equina syndrome requires timely diagnosis

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Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Cauda equina syndrome requires timely diagnosis

Don’t leave clinical decisions to the insurer’s approval process

Facts:

• An adult female in her 20’s develops lower back pain.
• Visit 1: After several days of no improvement, she sees a locums physician a
  t her community clinic and is treated symptomatically.
• Visit 2: After another week of worsening pain, she goes to the ED, is diagnosed with “Sciatica”, and treated with analgesics and muscle relaxants.
• Visit 3: 4 days later she follows up with the locums PCP at her community clinic because of new onset groin numbness. Symptomatic treatment is continued.
• About 3 weeks after onset, she begins having incontinence and difficulty urinating, severe enough that she has to “kneel” to urinate and wear an adult diaper. She tolerates this at home for another 6 days.
• Visit 4: She then returns to the locums physician at her community clinic. A “routine” MRI is ordered. The request is sent to her insurance company for authorization, and she is sent home with a refill of her pain medications.
• Visit 5: Another 5 days pass and she presents again to the ED, this time with obvious cauda equina syndrome (CES) from herniated disk, confirmed on MRI. She is transferred to a tertiary care center for surgery but is left with permanent bowel, bladder, and mobility issues.
• 4 days later her PCP receives the insurer’s approval for the MRI.
• A lawsuit is filed against the community clinic, the locums company used by the community clinic, and the locums physician supplied by the locums company.

Plaintiff: You should have gotten an emergency MRI 5 days earlier when I first complained of bladder problems. I was still able to walk then. If you had found my problem then, I would still be able to walk.

Defense: We may have dropped the ball but earlier intervention wouldn’t have made any difference. The locums physician was not our employee, and federal law allows us not to be liable for physicians who we do not directly employ.

Result: Settlement for an undisclosed amount, paid only by the locums company. A legal technicality exempted the community clinic from liability.

Takeaways:

1. There is no excuse for delaying an MRI once the need for the test becomes obvious. Do the right thing for the patient, not the insurance company.
2. Cauda equina syndrome from disk herniation is more common than spinal epidural abscess (SEA). Both should always be ruled out when evaluating patients with back pain. Tests (CRP/ESR for SEA, MRI for CES) are only needed if suspicion is high, but the MDM should document one’s clinical rule out.
3. Because duration of pain was relatively short and neurologic deficits were absent, the first ED visit gets a pass.
4. While there may be debate about whether timing makes a difference once neurological damage is present, early diagnosis and immediate surgery is the standard of care for cauda equina syndrome.
5. Follow up with patients with alarming symptoms. A phone call earlier in the course of her symptomatic progression could have led to an earlier – and emergent – MRI order.
6. Don’t depend on legal technicalities to avoid a malpractice settlement.

References:

1. Influence of timing of surgery on Cauda equina syndrome: Outcomes at a national spinal centre. Heyes G et al. J Orthop. 2018 Mar, 5(1): 210–215.
2. Cauda equina syndrome: the timing of surgery probably does influence outcome.Todd NV, British Journal of Neurosurgery, August 2005; 19(4): 301-306

“Be big enough to admit your mistakes, smart enough to profit from them, and strong enough to correct them.”

John C. Maxwell

From Dr. Katy Hanson at Hanson’s Anatomy: