Introduction
The claimant (KS) alleged that the trust had negligently failed to identify Cauda Equina Syndrome (CES), and that consequently she had experienced ongoing pain and suffering, whereas had this diagnosis been reached she would have had urgent decompression surgery leading to a better outcome. The trust argued that she did not, in fact, have CES and therefore even with the hypothetical surgery she would not have improved. Quantum had been agreed at £300,000 in the event of a liability finding against the trust. CES is a serious condition caused by compression of the nerve roots at the base of the spine which can cause paralysis and loss of bowel/bladder control if not treated promptly.
Details
KS had a long history of back pain and other medical issues. She first reported acute back problems in 2003 and thereafter had a number of surgical interventions. She also had long-standing urological difficulties. On several occasions in the past she had sought medical attention for symptoms potentially indicating CES, including after falls, but contemporary investigations did not reveal any evidence of cauda equina compression.
On 5 June 2017 she had a fall at work and consulted her general practitioner the following day. She described pain in her back that radiated down her legs and into her left buttock. The GP spoke to an orthopaedic registrar who recommended a hospital visit. Accordingly, KS presented at the Queen Alexandra Hospital, Portsmouth next day and was seen by an orthopaedic doctor who ordered an MRI scan. This was reviewed by Dr. Witham, a consultant radiologist, and it was upon her findings that the allegations of negligence were based.
Dr. Witham noted that the scan was affected by “much movement artefact”, but nevertheless concluded that the spinal canal “appears slightly tight at the L2-3 level and the L3-4 level where there is less CSF seen in the thecal sac”. She concluded that the patient had a “poor quality spine” and that KS was in too much pain to keep still. She also observed that there was mild central canal stenosis [abnormal narrowing]. The orthopaedic specialists then determined that the available clinical findings, including the MRI scan, did not warrant a diagnosis of CES. KS was therefore discharged from hospital later that day.
She sought a private opinion from a spinal surgeon on 12 June and he diagnosed cauda equina compression and proceeded the same day with surgical decompression and lumbar discectomy. He did not ask for a further MRI to be performed and does not appear to have made any consultation notes.
Despite this intervention, KS continues to experience a range of after-effects including urinary dysfunction necessitating intermittent self-catheterisation; bowel dysfunction; neuropathic pain; ongoing mechanical low back pain and an adjustment disorder.
Lawyers for KS alleged that Dr. Witham had wrongly under-reported the extent of spinal stenosis, failed to report severe central canal stenosis and failed to identify gross pathology at L2-3 and L3-4, with signs of cauda equina compression.
Dr. Witham gave evidence in court. She had been a consultant radiologist for over thirty years in 2017 and had seen at least one set of MRI images investigating possible CES every working day. She said that there were two red flags for CES on the MRI referral, namely reduced perianal sensation and difficulty passing urine. However, she disagreed that longstanding spinal canal stenosis might cause the onset of acute CES. Her view was that the scans did not show critical or severe stenosis. It was put to her that if there was any uncertainty of diagnosis, KS should have had a second MRI after analgesia; but Dr. Witham responded that this was not possible given the patient’s pain and moreover the hospital protocol did not allow for sedation in these circumstances.
The claimant’s radiology expert asserted that there was significant narrowing of the thecal sac and absence of cerebro-spinal fluid (CSF) at this point, which indicated compression of the cauda equina. The hospital’s radiology expert disagreed, concluding that the stenosis and facet joint cyst were of long standing and that there was no evidence of cauda equina compression. The scans were not unusual, but like many he came across routinely in his practice.
There was a similar division between the expert spinal surgeons: the claimant’s specialist thought CES could not be excluded and therefore there was an urgent need to operate; the trust’s thought there was no compression or CES, and hence no need for surgery.
Decision
The MRI scan demonstrated moderate central canal stenosis at L2-3 and L3-4. KS’s radiology expert had made errors in interpreting the scan, including identifying pathology at the wrong level. This did not inspire confidence, and therefore where there were differences between experts, Mr. Justice Sweeting decided that he preferred the views of the trust’s. The imaging did not identify any point at which there was sufficient constriction for the spinal nerves to be clumped together and subject to compression. The judge had considered the images personally and found that explanation to be compelling. Dr. Witham had emphasised her careful adherence to CES Pathway guidelines and her long and frequent experience of reviewing scans to identify whether there was CE compression.
There was no fixed standard for reporting scans and therefore a degree of subjectivity existed in practice. The difference between “mild” (as reported by Dr. Witham) and “moderate” (as the judge held) did not appear to convey a significant difference in assessment falling outside what was reasonably open to the radiologist to report.
There was no radiological evidence of cauda equina compression and therefore it could not be concluded that the scan was wrongly assessed. The claim accordingly failed.
Comment
This was a rather unusual case because it was argued on behalf of the claimant that she suffered from a condition (CES) which the judge, having heard all the evidence, concluded she did not. Whilst undoubtedly she has considerable ongoing health difficulties, on the balance of probabilities these are not due to CES. The claimant’s radiology expert failed to impress the court with various errors, and these led Mr. Justice Sweeting to reject his evidence. In all this was a sad experience for the claimant, given her continuing disabilities, but the judge backed a vastly experienced trust radiologist who had worked for over thirty years at consultant level.
