C (born on 2 August 1985) attended GP in 2010 with a history of back pain for two years. She struggled to control her bladder and the doctor identified a loss of perineal sensation. (paragraph 7)
C was referred… an MRI scan showed a large C4/5 disc protrusion with a rather small canal. (paragraph 8)
On 7 December 2010 [C underwent] a discectomy and decompression on the right side. (paragraph 9)
On 22 February 2011, C suffered an onset of lumbar back pain following a twisting injury. She attended at hospital… ‘no alteration bowel or bladder function feels normal when bladder opens’. C was allowed to go home and no follow-up was arranged. (paragraph 11)
On 17 March 2011 C attended D for review… D wrote: “… has clearly had an excellent result following an acute cauda equina syndrome and is making very good progress… she is asymptomatic at this time. Her wound is well healed although a little sensitive to touch but she has no nerve root tension signs and a normal autonomic function…For MRI scan July and review thereafter.” (paragraph 12)
MRI scan was carried out and it was reported that the L3/4 intervertebral disc shows a broad based posterior protrusion which along with degenerative canal stenosis at this level is resulting in moderate focal encroachment of the spinal canal with mild encroachment of bilateral neural canals. (paragraph 13)
On 21 July 2011, C was again seen by D…. wrote… : “… still describes bilateral moderate weakness, 4+/5 of L5 and S1 dermatome. She can walk a few hundred yards before her legs become very tired. I am also mindful of her severe overweight stature and BMI of 50. She still deliberately passes urine frequently to avoid any accidents and the MRI does confirm she remains with a significant disc prolapse at L4/5 and a lesser one at L3/4. I suspect also that when she is up and about this protrusion may be even more significant.
Her clinical situation is a difficult problem, least of which is knowing that she has a further mild cauda equina type syndrome but she is massively overweight and it would be revision surgery. I will discuss her situation with colleagues but I do feel bound to consider the surgical option as I do have some concern that she may rumble on with symptoms for a long period and as well as this I am worried about a sudden deterioration…” (paragraph 14)
On 22 September 2011, was seen… at her GP practice. The history given was a weakness in the legs and difficulty voiding urine. A diagnosis of cauda equina was made. C was referred to hospital as an emergency… (paragraph 16)
On 23 September 2011, C was seen by d who noted progressive symptoms since previous decompression and imminent cauda equina. He advised of the risk of permanent neurological loss in view of motor weakness and current bladder symptoms. The revision decompression was carried out later that day. (paragraph 18)
It is agreed that if there had been no neurological deterioration there would have been no need to proceed with urgent decompressive surgery. (paragraph 24)
The essential issues that must be determined are:
i) Did the Claimant suffer any neurological deterioration between March and July 2011? If there was such a deterioration what was the nature of that deterioration?
ii) Should early decompression surgery have been offered to the Claimant?
iii) Would the Claimant have come to surgery before suffering her serious deterioration in September 2011?
iv) If the Claimant had undergone early surgery would she probably have avoided her serious ongoing limitations and loss of mobility that followed the surgery carried out on 23 September 2011? (paragraph 25)
[There was detailed consideration of the facts and evidence.]
After considering all of the evidence, I make the finding that at the July appointment there was not a deterioration in the neurological symptoms. (paragraph 116)
Although it is not strictly necessary to make any further finding I consider that it is appropriate to consider the issue of whether decompressive surgery should have been offered to the Claimant on the basis there was a deterioration in her neurological condition. (paragraph 117)
…early decompressive surgery was not a reasonable treatment and should not have been offered to C. (paragraph 125)
…on the evidence the claim is not made out. There must be Judgment for the Defendant with costs… (paragraph 126)
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