Case Archive
Emergency Medicine, Neurosurgery, Orthopedic Surgery
Ref. # 976501

A 37-year-old woman slipped into a hole on the lawn of her parent's house, resulting in back pain. Five days later she presented in the afternoon to the ER with worsening lower back pain radiating into her legs, as well as numbness and tingling. She was noted to be in considerable pain with difficulty moving. Nursing notes documented the patient's history which included spinal stenosis, herniated disc in neck and back, fibromyalgia and chronic fatigue syndrome. The patient's current medications were listed as including Paxil, Vasotec, Flexeril, Motrin and Darvocet. The evaluating osteopathic ER physician also recorded the patient's history as well as the new complaint of back spasm located from waist to feet beginning that morning, progressively worsening and becoming more frequent. The patient was given intra-muscular Toradol and Valium, which was not helpful. The ER physician consulted with an orthopedic surgeon who did not examine the patient. Her treating pain management specialist was called to the hospital. He performed a sensory examination of the legs, buttock and sacral area, documenting pain in the lower back and sacro-iliac area, along with tingling and numbness. The patient was taken to the bathroom but could not urinate. The pain management specialist then provided an epidural steroid injection and discharged the patient with instruction to follow up in one week or any time if necessary. Two days later the patient presented to another hospital's ER complaining of an inability to move, numbness in the buttocks, and decreased sensation in the legs. She was evaluated by a physician's assistant and an osteopathic ER physician who believed the symptoms arose from the previously diagnosed spinal stenosis and herniated disc, possibly related to the recent epidural injection. Two and a half hours later the patient was incontinent, soaking her clothing and the floor. An MRI scan of the lumbar spine was performed. A radiologist reported significant spinal stenosis but no cord compression, a herniated disc at L4-5, and a distended bladder versus a large pelvic cyst. The patient was given intramuscular Toradol then discharged with a prescription for Ultram and instructions to follow up with an orthopedic surgeon. Two days later she was evaluated at the office of an orthopedic surgeon, who diagnosed acute cauda equina syndrome. He admitted her immediately to the hospital. The patient underwent urinary catheterization which removed two liters of urine, followed by surgical decompression of L3-4 and L4-5 and removal of a large herniated disc. She underwent several weeks of rehabilitation and continues to have difficult bowel and bladder function, perineal numbness and impaired mobility. A medQuest ER physician, neurosurgeon and two orthopedic surgeons independently reported physicians and other healthcare professionals at both hospitals negligently failed to diagnose acute cauda equina syndrome despite the documented classic symptoms of perineal numbness, difficulty ambulating and urinary incontinence. At the first hospital the patient's historical and new symptoms required rectal examination and perineal and perianal evaluation. The orthopedic surgeon, who negligently failed to see the patient, and the pain management specialist failed to recognize midline or bilateral nerve root impingement. At the second hospital no rectal examination was performed and the MRI results were misinterpreted or ignored. Urgent consultation was not obtained. These deviations from the standard of care increased the risk of harm to the patient.

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