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Author: Susie Hewitt / Code: MuC1, MuP1, SLO1, SLO12, SLO7 / Published: 08/04/2015

This is the third in a series of Emergency Casebooks from the virtual hospital CFN General, with key learning points for staff working in an Emergency Department.

Source: Litigation

Case summary
Mr P was a 55-year old gentleman who attended CFN General Emergency Department (ED) with back pain. The assessment nurse documented a pain score of 10/10. He had a history of lower back and said he had two slipped disks. The pain had become a lot worse and he now had painful legs. Mr P said he felt he needed to pass urine constantly.

Mr P was seen by Dr A. The electronic record indicates that Dr A went to seen Mr P at 22.19 and he made an entry in the clinical notes at 22.33. Dr A made the following notes: “50 y o. Known 2 lumbar disc prolapse. No neurology. Under physio care. Pain is +++ tonight. O/e well, same pain in the back only worse. CNS normal, no neuro, normal urine and defecation. Advice given, painkillers modified. GP f/u.”

Mr P returned to the CFN General ED the next day at 11.32. Mr P was seen by Dr B. She documented that Mr P had been diagnosed with sciatica and had a numb right foot. For five weeks he had suffered lower back pain initially radiating to the left buttock, which had been worse for the previous three days. The pain was now radiating down the back of both thighs and he described the pain as 10/10. Mr P stated that he had been incontinent of urine once during the night while he was asleep and when he woke in the morning. He described perianal and scrotal numbness since teatime the day before. There was no previous history of incontinence. No past medical history or allergies were noted.

On examination Mr P had no spinal tenderness however back pain developed on straight leg raising. Power was normal in the right and left leg. Paraesthesia was noted perianally and extending down the posterior aspect of both thighs.

Rectal examination showed reduced anal sensation and he was noted to be able to just contract the anal sphincter. Mr. P was referred to the duty orthopaedic team and he had an MRI at 16.00. This showed an L5/S1 disc protrusion with cauda equina compression. Mr P was seen by a spinal surgeon at 19.00 and he was in theatre by 20.00 that evening.

After surgery Mr P needed to self catheterise and had erectile problems. Mr P bought a case against the CFN General Trust alleging that the assessment on his first attendance was substandard and that earlier surgery would have prevented his ongoing urological problems. A specific allegation was around the failure to perform a rectal examination on the first attendance.

Dr A was asked to provide a written statement in which he stated that it was his “custom and practice” to do a full peripheral nervous system examination and a rectal examination. Independent expert opinion was obtained on breach of duty and causation.

The Trust considered admitting breach of duty based on the limited documentation in the ED notes however an independent expert spinal opinion concluded that the delay to surgery was not causative. The claimant’s solicitors were invited to exchange causation evidence and the claim was eventually withdrawn.

• The ED notes were sparse and this gave the Trust no option other than to admit breach of duty. In his witness statement Dr A relied heavily on his “custom and practice” in a number of areas of his history taking and examination of the patient. This would be a weak defence.
• Where a doctor relies on memory to say something did happen (in this case a rectal examination) and the patient says it did not, a judge is more likely to believe the patient given that doctors see lots of patients but this was a specific event for a patient.
• For litigation to be successful a claimant needs to show breach of duty and causation.
Cauda equina and litigation
Cauda equina syndrome (CES) is a rare condition with a disproportionately high medicolegal profile and costs. CES is usually characterised by the following so-called “red flag” symptoms:

• Severe low back pain (LBP)
• Sciatica – often bilateral but sometimes absent – especially at L5/S1 with an inferior sequestration
• Saddle and genital sensory deficit
• Bladder, bowel and sexual dysfunction

Three types of cauda equina syndrome have been identified:

• Rapid onset without a previous history of back problems
• Acute bladder dysfunction with a history of low back pain and sciatica (note dysfunction not just retention)
• Chronic backache and sciatica with gradually progressing CES

CES may be complete or incomplete and its onset may be either acute within hours or gradual over weeks or months.

There are a number of contentious issues from a medicolegal perspective. The literature is conflicting and this is not an easy condition to study. The issues are:

• The significance of delays in diagnosis and referral to hospital
• The risks and benefits of emergency versus urgent surgery
• The significance of surgical delay beyond 24 and 48 hours
• The prognostic significance of complete versus incomplete sphincter involvement and complete versus incomplete sensory deficit
• The prognostic significance of unilateral and bilateral leg signs

Good questions to ask patients with back pain:

• History of back pain. Put your finger(s) on the worst place
• Where is your leg pain?
• When did you last pass urine/open your bowels?
• Does your backside/genital area feel normal?
• Can you feel whether your bladder is full?
• Can you tighten your anus?
• Have you had any dribbling/leakage of urine?

Further RCEM Reading
Cauda Equina podcast
RCEM Reference: Lower Back Pain
RCEM Induction: Back Pain
RCEM Learning Module: Back Pain

Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome?
Cauda equina syndrome: a review of the current clinical and medico-legal position. Gardner A, Gardner E, Morley T