Author: Chuck Pilcher, MD FACEP (Editor, Med Mal Insights) // Reviewers: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
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Chuck Pilcher, MD, FACEP
Editor, Med Mal Insights
Missed cauda equina syndrome
Glaring signs and rampant miscommunication over a 2 week period leads to tragic ending. Could this happen in your system?
Facts/Timeline:
0 hours:
A young adult presents to the ED of a major university hospital with a 2 day history of 10/10 back pain, intermittent tingling in both legs, and difficulty walking. Pain is aggravated by sneezing and bending over. His last BM was 2 days ago, and he has had 2 episodes of incontinence. PMH includes a history of intermittent back pain with multi-level disc bulges on an MRI 1 year prior. The emergency physician attributes patient’s incontinence to inability to use the bathroom due to pain. Patient is unable to stand on scale to be weighed during exam. MDM records straight leg raise positive at 20-30 degrees bilaterally. Diagnosed as “flare-up of chronic back pain with radicular symptoms.” Discharged as “neurologically intact” with “no evidence of cauda equina syndrome.” Instructed to see PCP in 5-7 days and have PCP order an outpatient MRI.
20 hours: Patient returns to the ED with worsening symptoms. Exam unchanged with limited ROM and tenderness in lumbar spine. Reflexes 2+, no foot drop. Outpatient MRI ordered for following day. Resident enters note in chart for attending emergency physician to review MRI report when available and plan next steps.
42 hours: MRI shows central disc extrusion at L3-4 and 4-5 with complete effacement of thecal sac and compression of all nerve roots below the L3 level. No evidence that radiology informs either the ED or PCP. No action is taken.
Day 2: Patient presents to a second ED in the same university system. That EP acknowledges the MRI from a year ago but says nothing about the MRI done only 10 hours previously. After a brief exam, the patient is given IM ketorolac and discharged 47 minutes after arrival. He is advised to be seen by a spine specialist at the system’s main hospital and follow-up with the PCP in 3-5 days.
Day 2.5: The main hospital’s “Care Coordinator” notes the need for an appointment with the spine clinic and calls the patient. He reports inability to walk, so Care Coordinator orders a wheelchair. Being a holiday weekend, the patient is advised to return to the ED as needed.
Day 3.5: Patient again presents to the main hospital ED with worse symptoms and another episode of incontinence. Seen by an ARNP who documents leg strength as 5/5 and “does not have cauda equina syndrome” (apparently based on first EP’s assessment.) Unaware of recent MRI, ARNP notes “patient is due for a possible MRI in near future… Will order MRI for tomorrow…” Neurosurgery and a pain specialist are consulted by phone but no change in plan. He is discharged with a diagnosis of bilateral sciatica and herniated lumbar disc. He is instructed to see PCP and spine clinic in 1-3 days. Attending EP amends a note that an MRI was done at last visit and says there is “no CES by history or exam.”
Day 5.5: Radiology technician notes the unusual order for a second MRI in 3 1/2 days. Sends email to Care Coordinator: “There was an MRI done 3 days ago. Does patient need another one?” Nothing seems to happen for another 36 hours.
Day 7: Patient presents to university’s affiliated neighborhood clinic with continued symptoms. Call placed to original ED about spine clinic appt. “Will check and respond.” Discharged with prescription for opioid.
Day 8: Spine clinic scheduler calls patient to schedule appt for Day 10 and learns that patient has lost bladder control and is unable to walk. Informs PA-C in spine clinic who advises patient to come to hospital immediately.
Day 8, later: Patient presents to ED and taken immediately to OR for cauda equina syndrome.
Day 12: Develops spinal hematoma and returns to the OR for decompression.
Post-op: Leaves hospital wheelchair-bound with permanent paraplegia. An attorney is contacted and the case sent to experts for review.
Plaintiff: The lack of concern for a serious and seemingly obvious neurologic problem is astounding. Multiple caregivers failed to access or read the patient’s medical record. Mis-communication among providers was rampant, mostly dependent on email and a messaging app rather than real-time communication. Mid-levels and physicians seemed to live in 2 different worlds. The only person who demonstrated common sense was the radiology tech who inquired why a second MRI scan in 3 days was needed when the first one revealed the gravity of the problem. The information was available but never seen or acted on until too late.
Defense: No information available.
Result: The case was dropped by the plaintiff attorney when his client died by suicide a year later.
Takeaways:
- This patient’s gender was purposely not disclosed in the above story. “They” were obese and in the process of transitioning from female to male.
- Avoid implicit biases such as race, gender, appearance, sexual orientation, etc.
- Never assume that a patient with chronic back pain has not progressed to a neurologic emergency.
- Avoid anchoring bias and confirmation bias, both heavily present in this case.
- Had a less assumptive assessment been done on the initial visit, a neurologic emergency would have been identified and the whole sad scenario played out differently.
- “Bilateral sciatica” is a red flag.
- Evaluate for urinary retention evaluate for perineural sensory changes.
- Don’t assume that your chart notes and messages will be read. Communication between providers at all levels – attendings, residents, APP’s, nurses, care coordinator, patient – was atrocious. The telephone is still a useful tool.
- Read the notes of others – nurses, other docs, EMT’s, etc.
- This case ended in a tragic and completely unnecessary outcome, the result of minimizing signs and symptoms and horrible miscommunication.
References
- Cauda Equina Syndrome: Why do we miss it? How to improve? Priester JH, Bisanzo M. emDocs June 13, 2021. https://www.emdocs.net/cauda-equina-syndrome-why-do-we-miss-it-how-to-improve/
- Long B, Koyfman A, Gottlieb M. Evaluation and management of cauda equina syndrome in the emergency department. Am J Emerg Med. 2020 Jan;38(1):143-148.
- https://www.acepnow.com/article/learn-to-spot-and-treat-cauda-equina-syndrome/
- Cauda Equina and Conus Medullaris Syndromes. Dawodu ST. Medscape eMedicine. Updated Dec 30, 2024 https://emedicine.medscape.com/article/1148690-overview
- Cauda equina syndrome: a review of the current clinical and medico-legal position. Gardner A. et al. Eur Spine J 20, 690–697 (2011) https://upload.orthobullets.com/journalclub/pubmed_central/21193933.pdf
