My GP Mistook Cauda Equina Syndrome For Sciatica
If your GP mistakenly diagnosed you with sciatica when you did in fact have cauda equina syndrome, you need to talk to a solicitor about your options.
Differentiating sciatica and cauda equina syndrome
Sciatica is a painful but non-serious condition that can be managed conservatively. This differs to cauda equina syndrome which is a medical emergency which must be treated with urgent decompression surgery.
Sciatica and cauda equina syndrome are similar in that they both cause back and leg pain. However, cauda equina syndrome has further neurological symptoms that should raise the suspicion of cauda equina compression rather than sciatica.
If your GP failed to take note of these other symptoms, causing a delay in the diagnosis and treatment of your cauda equina syndrome, you need to talk to a solicitor. It may be that your GP has acted negligently, meaning that you would be eligible to pursue a claim for compensation.
Generalised back pain
Back pain is a very common complaint in general practice. It is responsible for 7 to 10% of all consultations in general practice, which would amount to a few hundred consultations every year for a full-time GP.
The great majority of complaints of back pain are simply mechanical problems with the spine and associated soft tissues. A small proportion of cases are due to nerve root compression, usually caused by prolapsed intervertebral discs. This usually manifests itself as 'sciatica', which involves pain running down the leg.
Sciatica
Peripheral nerve root pain, or 'sciatica', is regularly seen in general practice. It is caused by extruded material from a disc prolapse pressing on the roots of peripheral nerves as they exit from the spinal canal between vertebrae.
As set out in medical guidelines, which are representative of normal clinical practice, is that the signs of a disc prolapse causing peripheral root pain (sciatica) are:
- Unilateral leg pain worse than low back pain
- Radiation to foot or toes
- Numbness and paraesthesia (tingling)
- Straight leg raises produces leg pain
- Localised neurological signs
In severe or persistent cases, a referral may be made to an orthopaedic surgeon, but the problem is rarely an emergency. Consequences can include weakness and wasting of muscles, as well as pain and sensory disturbances. An absent ankle jerk reflex can also occur.
Cauda equina syndrome
Cauda equina compression is, by contract, rare. The average GP might see a case only once every 15 years or more. Some GPs will not see a case in the whole of their professional career.
The cauda equina are the nerve tissue occupying that portion of the lower spinal canal below the dura. Compression of these nerves causes lower motor neurone signs such as weakness in the legs, diminished reflexes and decreased muscular tone.
Importantly, the sacral nerve outflows controlling bowel and bladder function below the site of compression can be affected. Cauda equina compression would therefore be expected to cause loss of bladder sensation and sphincter tone. This will result in urinary incontinence, but it may also make it difficult for the bladder sphincter to relax, causing retention of urine.
In general practice any symptom of sphincter disturbance has to be taken seriously. Furthermore, the signs and symptoms that suggest the need to consider cauda equina compression are:
- Bilateral sciatica (see explanatory note below)
- Saddle anaesthesia (see explanatory note below)
- Loss of bladder sensation and urinary incontinence
- Bowel sphincter disturbance
- Gait disturbance (which has a neurological cause, not simply walking being painful and therefore difficult)
Bilateral sciatica
It is important to highlight that bilateral leg pain is not the same thing as bilateral sciatica. Ordinary low back pain commonly radiates to both thighs. Nerve root involvement is more readily recognised where there is pain or sensory disturbance below the knee.
Bilateral sciatica would imply the need for a consideration of cauda equina syndrome because if a disc protrusion is big enough to cause radicular symptoms on both sides, it could equally cause central canal compression.
Saddle anaesthesia
Saddle anaesthesia refers to reduced sensation in the area that would be in contact with a saddle if sitting on one. Medically speaking, saddle anaesthesia is an issue involving the sacral dermatomes, especially S2 to S5. This means that there is reduced sensation and/or numbness around the buttocks, thighs, perineum and genitals.
GP assessment for possible cauda equina syndrome
In some cases a patient will present first time with the red flag symptoms of cauda equina syndrome. But in other cases a patient will repeatedly return to their GP will 'new' symptoms. A GP must be careful to consider the progression of the symptoms as a whole, watching out for additional symptoms that indicate the possibility of cauda equina compression.
If a patient presents with the symptoms of cauda equina syndrome, an assessment should be undertaken without delay. A GP assessment of a person with possible cauda equina syndrome should include:
- Asking about the history of symptoms, particular bladder dysfunction and sphincter disturbance
- A test for skin sensation in the saddle area
- A neurological examination of both legs
- A check for a palpable bladder
- A check for anal tone
Regarding anal tone, a GP may decide this test is unnecessary if the patient is being referred to hospital.
GP referring a patient to hospital with suspected cauda equina syndrome
If this assessment supports a suspected diagnosis of cauda equina syndrome, a patient must be referred to hospital. According to the Royal College of GPs, this referral should be 'urgent'. But according to the National Institute for Health and Clinical Excellence (NICE), this referral should be 'immediate', meaning within a day.
Whichever definition you take, an acceptable standard of care requires a rapid referral, with the GP contacting the hospital directly over the telephone rather than by a letter. There should be a discussion with an appropriately qualified doctor at the hospital, followed by admission to hospital as soon as practicable.
GP fails to diagnose cauda equina syndrome
Many of the cauda equina claims we handle involve a claim against a GP. Often this is because a GP fails to ask a patient about their symptoms and whether they have progressed, and specifically whether there were any cauda equina syndrome symptoms. If there were such symptoms/signs, a GP should make a same day referral. A failure to achieve this standard of care will amount to a breach of duty.
If this breach of duty causes a patient to suffer harm – for example, long-term neurological complications – there will be grounds for a medical negligence claim. Contact us today for more information.
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