Cauda Equina Syndrome: A Missed Diagnosis
In a recent case a GP was found to have breached his duty to his patient by failing to spot the signs of cauda equina syndrome and refer her urgently to hospital.
The case was Shaw v Stead (Shaw v Stead  EWHC 520 (QB) and judgment was given on 1st March 2019. The case shows the importance of recognising the ‘red flags’ of cauda equina syndrome.
What is Cauda Equina Syndrome?
Cauda equina syndrome is where the bundle of nerves at the bottom of the spinal cord become compressed. It often happens because a disc slips and puts pressure on the nerves. It may happen because of ‘stenosis’ – when the bony growth narrows the space around the cord.
The condition tends to progress rapidly. It is a serious condition and can cause significant disability. It leads to pain and weakness down both legs, numbness, loss of bladder and bowel control and loss of sexual function. It is a surgical emergency. It is important that patients get to hospital and have surgery quickly to avoid permanent damage.
What are the ‘Red Flags’ of Cauda Equina Syndrome?
Many patients with cauda equina syndrome have severe back pain. But back pain alone is not enough. There are certain well-known symptoms which are called ‘red flags’. They are:
1. Any change in sensation in the saddle area;
2. Any change in bladder or bowel function;
3. Severe or progressive loss of power in the legs; and
4. Leg pain or loss of feeling in both legs (but not just one).
What should a GP do?
When a patient consults a GP with acute low back pain, the GP should take a history and carry out an examination. The examination should look for any red flags. If there are red flags, the GP should refer the patient to hospital for investigation. If there are not, he or she should advise seeking urgently medical attention should red flag symptoms develop.
What happened in this case?
Mrs Shaw was working as a teaching assistant. On Thursday 23rd May 2013 she suffered an injury to her back. She was in immediate pain. On the afternoon of Friday 24th May 2013 one of the GPs at her practice prescribed her painkillers. At 15:16 on Saturday 25th May 2013 she telephoned the surgery out of hours and spoke to a nurse. The nurse recorded, ‘Today legs have gone numb, tingling..’ This suggests one red flag (‘leg pain or loss of feeling in both legs’). At 15:42 she telephoned again and was advised to attend the out of hours service, although this time the note did not record any red flags.
Her husband took her to the appointment when she saw Dr Stead. The judge accepted her account which was that she was in a wheelchair and had to be helped onto a couch. Dr Stead recorded the history but wrote ‘no red flags’. At trial he could not remember the appointment but he said he must have tested for them. He diagnosed sciatica and advised changing the painkillers.
The judge found that there were 2 features which suggested Mrs Shaw nevertheless had red flags which Dr Stead failed to notice. The first was that earlier in the day she got up to go the toilet, was unable to pass urine but then had an accident on the way back. This suggested bladder dysfunction (a red flag – ‘any change in bladder or bowel function’). The second was that when she got up to go to the surgery she had difficulty walking because her legs felt weak (also a red flag – ‘loss of feeling in both legs’). In fact she described it as feeling ‘like Bambi’.
On Monday 27th May 2013 she again called the out of hours service. She was struggling to walk and according to the note her legs felt ‘cold and like jelly’. She saw a doctor who recorded a loss of power and sensation. He took advice from an on-call surgeon and sent her to Accident and Emergency. She then had a MRI scan which showed a large central disc prolapse at L3/4 (2 of the vertebrae of the lower spine) and was sent for emergency surgery.
The judge therefore found that Dr Stead breached his duty on 25th May 2013 by failing to note red flags of cauda equina syndrome and refer Mrs Shaw urgently to hospital.
Because the issue at trial was only whether there was a breach of duty by the GP and not what harm it caused, the trial did not deal with the outcome.
Why is the case important?
The case is important because cauda equina is a very serious and disabling condition. If diagnosed quickly and treated by urgent surgery people can make a very good recovery. Where diagnosis is delayed people can suffer significant avoidable harm. The key to diagnosing the condition correctly is noting whether there are ‘red flags’ and then arranging for MRI scans. Treatment involves urgently neurosurgery to remove whatever is pressing on the nerves before the damage become permanent.
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