Cauda Equina Syndrome settlement

Case Report

In The Matter Between:

TC

-v-

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

Background to the Claim

39 year old TC had a history of lower back pain and had consulted her GP on a number of occasions during 2003/4.

On May 6 2004 she had a particularly severe episode of back pain that was unresponsive to analgesia. She contacted her GP by telephone and an appointment was made for her to attend the surgery on May 10 2004 if the symptoms had not improved.

The pain continued and at about 7am on May 8 2004 suddenly worsened. TC felt the urge to pass urine but was unable to stand and get to the toilet.

She was seen at home by her GP who arranged for her to be taken immediately to A&E where severe backache was noted together with increased urinary frequency. Perineal and peri-anal sensations were noted to be in tact. She was admitted for further investigations.

On the evening of May 8 (or possibly May 9 - the medical notes and evidence were unclear on this point) the nurses recorded that TC had "some altered sensation in the saddle area". Following a ward round on May 9 it was noted that although there were no bowel or urinary symptoms perineal sensation was reduced. The impression was of a L5/S1 disc prolapse creating pressure on the descending nerve root. The plan was for an MRI scan and review.

On May 10 2004 the nurses twice recorded that TC was complaining of numbness of the thighs and perineal area and a lack of sensation to pass urine. The MRI scan taken that day showed a very large disc fragment that was close to becoming sequestrated (separated)

The following day (May 11) TC was reviewed again and it was noted that she was complaining of numbness in the lower back and thighs and that perineal sensation was also reduced. Initially she seemed to be passing urine fairly normally but later had to be catheterised for retention.

At 23.50 hours on May 11 she was reviewed again as she could not pass urine. Peri-anal sensation was noted to be markedly reduced. The registrar was called and she decided to inform the consultant the following morning with a view to proceeding to decompression surgery.

On the ward round on May 12 2004 a possible diagnosis of Cauda Equina Syndrome (CES) was made and an opinion from a neurologist (Dr A) was sought. Dr A saw TC that afternoon and listed her for urgent lumbar spine decompression the following morning.

Decompression of L5/S1 was undertaken on May 13 2004, 5 days after it was first noted that there was a degree of loss of perineal sensation.

TC experienced a number of problems following the surgery and in 2007 she had a spinal fusion because of continuing pain. She has also had a number of facet joint injections as a means of pain relief.

Particulars of Injury

The compression of her spinal cord over a period of several days has left TC with a significant and permanent disability. She has limited mobility and uses crutches or a wheelchair or a scooter when outside the house, although she spends most of her time at home. She has little bowel or bladder control and has to self catheterise. She has no sexual feeling at all and, understandably, this has affected her relationship with her husband. She is depressed and continues to experience considerable back pain.

TC ran her own cleaning business before the development of CES but this has had to be sold as she can no longer undertake such work. It is unlikely that she will ever work again.

Case for the Claimant

TC claims that the significance of the red flag signs of severe back pain associated with perineal numbness and bladder involvement went unrecognised for 4 days.

Signs of CES were apparent from May 9 when, according to the claimant, an MRI scan followed by urgent surgery should have been undertaken.

TC also claims that had decompression surgery been undertaken at any time up to, and including, the morning of May 12 she would have made a full recovery, save for some minor residual backache that would have had no effect on her ability to work.

Case for the defendant

The defendant admitted breach of duty in relation to failure to operate on May 11 2004 but denied causation based on the claim that TC would have suffered some permanent neurological damage anyway even if surgery had been carried out sooner.

Following exchange of medical evidence the defendant clarified their case on causation indicating that the admitted delay in undertaking surgery had increased the severity of symptoms experienced by TC. These included increasing the impairment of sexual function to a total loss of sensation, a slight increase in disturbance of urinary function requiring self catheterisation and a slight increase in bowel problems in terms of urgency of defecation and possible faecal stress incontinence. The defendant denied that TC's chronic back pain would have been avoided by earlier surgery.

Court Proceedings

Views on the urgency of decompression surgery in cases of CES vary greatly and this was borne out by the differing opinions of the experts in this case.

Mr Webb, the defendant's orthopaedic expert, was of the view that by May 11 2004 the CES was still incomplete and had surgery been undertaken on this date in all probability TC would have recovered bowel and bladder function, although possibly with some residual bladder symptoms. After this date the CES became complete, which means that the neurological damage was irreversible.

The defendant's neurological expert, Mr Maurice-Williams, held a somewhat different view. He believes that the CES at no time became complete. He states in his report that had the surgery been carried out as early as May 9 2004 TC would, on the balance of probabilities, have regained more or less normal sphincter control, but by May 11 2004 marked and permanent disturbance of bladder and bowel would have occurred.

Following exchange of medical evidence, but prior to experts meeting, the defendant made an offer of £250,000 (gross of CRU repayments). At that time the case was difficult to value given a degree of uncertainty in relation to TC's prognosis and in view of the fact that a final schedule of loss had not been prepared. TC was anxious to settle as quickly as possible so after the initial offer was rejected a counter off of £375,000 (gross of CRU) was accepted.