38 Trial Lawyer • Fall 2023 Rhett Fraser By Rhett Fraser OTLA Guardian Larry was worried. He kept waiting for a neurosurgeon to come visit him in his hospital room, but the hours ticked by without anyone coming to see him. Earlier that morning, Larry sent an email to his primary care physician that he was experiencing symptoms of sciatica (pain extending from his lower back to his left leg, numbness from his groin to his left toes) and difficulty urinating. He told his physician he could no longer hold himself up on his leg, indicated his pain that morning was acute and that his legs felt cold to the touch. His primary care physician urged him to go — that day — to the local area hospital’s emergency department and told him that he likely needed an MRI. At the hospital emergency department, Larry reported he was beginning to experience urine leakage and explained about the numbness that extended from his groin to his left toes. Examination revealed sensory deficits to his left thigh, radiculopathy in his left leg and diminished motor weakness. An MRI was appropriately ordered, and he was admitted for further evaluation. His MRI results came back that evening within an hour, revealing a large L2-L3 disc herniation. Armed with prior clinical findings and this new concerning imaging, the hospitalist on duty made the correct diagnosis: cauda equina syndrome. Cauda equina syndrome (CES) has a funny name (“cauda equina” means “horse’s tail”) but the condition is no laughing matter. CES carries extremely serious implications, especially if not diagnosed and treated promptly. The syndrome is a nerve root problem, in which there is pressure on the nerves at the very bottom of the spinal cord. This collection of nerves, which resembles the tail of a horse, gives the syndrome its name. CES is most frequently caused by a ruptured disk in the lumbar area. It is generally rare, but, because it’s so serious, doctors need to take measures to rule it out if a patient is having any of the symptoms. What a physician cannot do is take a “wait and see” approach when a patient is experiencing CES. The longer it takes to get diagnosed and treated, the greater the chances of long-term or permanent problems. Once Larry’s diagnosis was made, the next correct course of action was emergency surgery to decompress the nerve impingement. The hospitalist recommended Larry receive supportive care, an urgent referral to neurosurgery, and that he be NPO (nothing by mouth) in anticipation of imminent surgery. The hospitalist paged neurosurgery several times to reach the on-call surgeon. The expectation was the on-call surgeon would perform surgery right away. When a patient is diagnosed with CES, surgery must be performed as quickly as possible to relieve pressure on the nerves and prevent permanent damage leading to paralysis or other long-lasting outcomes, including loss of bladder, bowel and sexual function. THE HORSE'S TAIL A CASE STUDY OF MEDICAL MALPRACTICE
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