September 2nd, 2014|
Acute cauda equina syndrome (CES)is a catastrophic medical condition which results in neurological deficits in the lower extremities and loss or impairment of one’s bowel and bladder function. It can result from compression of the spinal cord due to herniated disc, spinal epidural hematoma or infection. Acute cauda equina, as distinguished from a chronic form, can occur suddenly, within hours or days of an insult to the spinal cord. From time to time, attorneys are asked to review these tragic cases to see whether earlier recognition of symptoms and earlier interventions would have probably changed the outcome.
While most medical experts on the subject agree that acute CES is a surgical emergency, there is very little agreement beyond that. Many articles have been written on the relationship between surgical timing of decompression and neurological outcome. Controversy exists between those advocating emergency surgery versus urgent surgery. Some experts, experimenting on dogs, have concluded neurological function after compression depends on the force and duration of compression and the rapidity of onset of motor deficits. Other experts, reviewing clinical literature, conclude recovery does not depend on the timing of surgery but on the pre-operative neurological condition of the patient, with better results in those who experience incomplete motor and sensory loss. Some studies demonstrate that patients treated in less than 12 hours had better outcomes and conclude that risk likely increases over time so that earlier surgery is always preferable to later surgery. Other studies conclude that there are no significant differences in outcome between decompression within less than 24 hours and the 24 – 48 hour groups. Patients who had surgery more than 48 hrs after onset of CES were at 2.5 times the risk of continuing to have a urinary deficit; 9.1 times the risk of continuing to have motor dysfunction; 9.1 times the risk of continuing to have rectal dysfunction; and 3.5 times the risk of continuing to have a sensory deficit. But this latter study has been criticized as being partially flawed in addition to having used an inappropriate methodology.
Healthcare professionals have to be highly suspicious of any patient who reports neurological deficits such as loss of sensation in parts of the legs or loss of strength in the muscles which move the hips, knees, ankles and feet. Patient complaints of diminished bowel and bladder dysfunction can cause confusion depending on the patient’s normal schedule or, in a post operative setting, the effects of anesthesia or catheter placement.
In the context of post operative spinal surgery, the nurses in the recovery room or on the floor must be vigilant in assessing a patient’s oral intake and urinary output and drawing any conclusions about potential urinary incontinence. Assessing neurological functions – sensation and motor strength – and comparing them to the assessments of nurses on prior shifts is critical since any significant change in a patient’s neurological condition must immediately be brought to the surgeon’s attention. Any significant changes require a neurological exam and, if CES is in the differential diagnosis, a STAT MRI should be ordered to rule in or rule out spinal compression.
Although nurses are generally considered the patient’s advocate, the patient’s family and the patient him/herself should be vocal about any details that may affect the diagnosis and treatment. For example, a patient who has claustrophobia and is about to be sent into an MRI must convey that information in a clear and unmistakable way so that the healthcare team can assess the effectiveness of oral anti-anxiety medication, call for an anesthesia consult, or send the patient to a facility with an open MRI. These unanticipated delays can have catastrophic effects on the patient’s outcome.
In litigation, these cases are often defended on the basis that either the patient did not exhibit the classic symptoms associated with CES or that by the time the symptoms could have been recognized, permanent paralysis and bowel and bladder dysfunction could not be reversed. However, most surgeons will have to admit that CES is a surgical emergency; that any change in the patient’s neurological presentation requires an immediate neurological evaluation and MRI; and that no reasonable surgeon in that setting would wait 24-48 hours to operate on an otherwise healthy patient because studies suggest that there is no significant difference in outcomes between the 24-48 hour group and the less than 24 hour group. In other words, given the opportunity, most surgeons would operate emergently.
Authored by Attorney David M. Paris