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Texas spine surgeon ignores textbook signs of cauda equina syndrome

Patient is left with permanent disabilities that could have easily been avoided

Cauda equina syndrome is a dangerous medical condition that can occur after lumbar spine surgery. When it occurs, it’s a medical emergency that requires immediate return to the operating room. If nurses, the spine surgeon, and other physicians aren’t on the lookout for the classic signs and symptoms, it can cause a delay in surgery and permanent motor and sensory disabilities for the patient.

The cauda equina is a bundle of nerves at the bottom of the spinal cord. Its name comes directly from a Latin phrase describing a horse tail, because that's what the collection of nerves looks like. In most people, the cauda equina is made up of lumbar nerves (L2–L5), sacral nerves (S1–S5), and the coccygeal nerve.

Together, the cauda equina nerves play important functions, including providing motor and sensory nerve coverage to the pelvic/genital area, lower extremities (legs, knees, ankles, feet), and anal area.

Cauda equina syndrome occurs when something causes compression on these critical nerve roots. The compression can affect one or both sides and the impairments vary depending on which spinal level the compression is present.

For instance, here at Painter Law Firm we’re currently working on medical malpractice case involving a woman in her 60s in the Dallas/Fort Worth (DFW) area.

Her medical history began with a lumbar laminectomy surgery at the level of L4–L5, to address persistent lower back pain. A laminectomy is a surgical procedure where a spine surgeon removes the back portion of one or more vertebrae. The purpose of the procedure is to decompress the area and remove pressure from the spinal nerves.

Unfortunately, after several months, the patient’s pain returned. She initially tried conservative treatment through epidural spinal injections (ESIs), but finally gave in and saw another spine surgeon. The second spine surgeon recommended fusion surgeries at the same level of L4–L5. A fusion surgery involves a spinal surgeon using surgical implants to permanently connect two or more spinal vertebrae. In her case, the goal was to help correct the spinal weakness and instability in that area.

The patient consented to proceed with the surgery at a hospital. According to the spine surgeon's operative report, he encountered an incidental durotomy during the procedure and attempted to repair it. An incidental durotomy is an unintended surgical puncture of the protective layer around the spinal cord or cauda equina called the dura mater.

An incidental durotomy increases the patient’s risk for epidural hematoma (bleeding followed by a collection of blood near the spinal cord or nerve roots) that can cause damage by compressing the spinal cord or nerve roots. This happens because the incidental durotomy releases cerebrospinal fluid (CSF) pressure that allows spinal blood vessels to become engorged with blood, causing increased bleeding at the surgical site.

It’s often not a deviation from the standard of care—what a reasonably prudent spine surgeon would do under similar circumstances—to have an incidental durotomy during a lumbar spine procedure, but that’s not the end of the question. But because of the increased risk of epidural hematoma, a reasonably prudent spine surgeon must be extra vigilant in the postoperative period by looking for signs and symptoms consistent with spinal cord or nerve root compression.

At the level of this patient’s surgery, the attention of the nursing staff and spine surgeon should be focused on the risk of cauda equina syndrome. The type of abnormal signs and symptoms that the nursing staff should be concern of include lower extremity motor weakness, numbness from the waist down, saddle anesthesia (numbness in the general and bottom areas), and urinary retention. These are the classic, textbook signs of cauda equina syndrome.

When a patient has urinary retention, along with other neurologic deficits, it’s extremely important for the spine surgeon to carefully and immediately evaluate and document what’s going on with the patient. The physical exam must include a sensory exam of the perineal region, including the genitalia, perianal region, and buttocks. When a patient has urinary retention, in combination with altered perineal sensation after a lumbar procedure, the spine surgeon should have a high suspicion of cauda equina syndrome and order a stat (as soon as possible) MRI to guide possible surgical decompression of the suspected areas where the spinal cord or cauda equina are compressed.

In the case that were currently working on, the patient began having a well-documented, persistent inability to void urine very quickly after her lumbar fusion surgery. The patient could feel her bladder was full and repeatedly experienced extreme pain until the nursing staff manually evacuated her bladder with a catheter.

When the nursing staff informed the spine surgeon of the patient urinary retention, accompanied by bad neurologic signs including drop foot and loss of perineal sensation, the spine surgeon appropriately ordered an MRI. When the radiologist reported to the spine surgeon that the MRI report was abnormal, the spine surgeon decided to discharge the patient rather than take her back to the operating room for emergency surgery. It's hard to imagine a legitimate explanation for that bad decision!

Now, the patient is left with permanent drop foot, complete loss of feeling in the saddle area (genitalia to buttocks), leg pain on one side, loss of motor function to her toes on one side, inability to urinate without self-catheterizing multiple times each day, frequent urinary tract infections, and loss of control over bowel function.

At a time when she wanted to enjoy her retirement with her husband and family, she’s instead isolated and immobilized by her loss of basic functions. Sadly, these permanent impairments could have been avoided if the spine surgeon had given greater attention to the post-operative care of this patient, given the fact that he knew that her surgery had been complicated by his accidental puncturing of the dura mater. Yet, instead of following his patient personally, he sent a nurse practitioner to handle the post-operative care.

If you’ve been seriously injured because of poor spinal surgery or post-operative care in Texas, then contact a top-rated, experienced Houston, Texas medical malpractice lawyer to discuss your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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