Lower back pain affects thousands of people each year. But in rare cases, back pain coupled with pain, numbness or weakness in both legs, or numbness around the genitals and anus, can be a warning sign of cauda equina syndrome (CES) which is compression of the 'horse's tail' nerves at the bottom of the spine. If CES is suspected, it should always be treated as a medical emergency to reduce the risk of permanent paralysis or nerve damage.

Legal action was taken against North Cumbria Integrated Care NHS Foundation Trust through Christine Brown at Medical Solicitors after the orthopaedic team discharged the claimant ‘C’ without a proper investigation of her symptoms.

The main issue arose when a consultant failed to refer C for a MRI scan, despite two junior doctors suspecting a neurological cause of her lower back pain. The MRI scan would have confirmed a large disc prolapse, or “slipped disc”, that was compressing the cauda equina nerves.

C eventually underwent decompression surgery 11 weeks later, but sadly the delay has left her with permanent injuries that affect her daily life, including severe loss of bowel and bladder function, as well as a foot drop.

Following her injuries, C struggled to look after or play with her two young children, walk her dogs, or drive a manual car. Active housework, such as tidying, cleaning, lifting washing and cooking pans, or gardening, became impossible. Once her children were older, she intended going back to work, but her symptoms restrict her ability to work. She suffers from severe anxiety and lack of social confidence due to her bowel and bladder problems.

C was 31 when she was referred urgently to hospital by her GP after experiencing lower back pain for two weeks which had worsened in the previous 24 hours along with reduced sensation to her left leg, and saddle paraesthesia, or loss of sensation to the inner thighs and groin, which is a red flag symptom for CES.

Despite this, C didn't receive a perineal examination which would have indicated abnormalities. The doctors needed to assess sensation, anal reflex and anal tone and the ability to contract the sphincter. Instead, a rectal examination was carried out and noted to be normal, but C could not feel the examination.

C disputed medical notes by an orthopaedic senior house officer who recorded no bladder or bowel issues. The doctor noted low back pain radiating to the back of the right thigh and leg, and numbness in the left leg and carried out a neurological examination noting asymmetrical reflexes and weakness in both legs. The doctor suspected a progressing neurological condition and planned for a MRI scan the following morning as the scanner had closed for the day.

Later that same evening, an orthopaedic middle grade doctor noted power in left and right lower limbs in all muscle groups was 5 (normal power) with a mild reduction in sensation at the lumbosacral joint on the left. The plan was to give pain killers and get her mobile and, if symptoms worsened, to arrange an MRI scan, or discharge if not.

The following morning, C was seen by a consultant who did not examine her and noted she was sitting comfortably without pain in a chair and there was no neurological abnormality. The consultant noted she did not normally suffer back pain yet diagnosed low back pain with a history of chronic back pain, which was incorrect. C was discharged with no follow-up.

This was not a case of simple lower back pain. There was a clear history of neurological changes which required urgent MRI investigation.


The disc prolapse was eventually diagnosed by MRI scan 11 weeks after the hospital admission. C was transferred to a hospital 60 miles away where she underwent emergency surgery to decompress the spine and remove part of the disc that was pressing on the nerves.

C’ s case on causation was that a perineal examination would have found abnormalities and an MRI scan would have shown a large central disc prolapse that was pressing on the cauda equina nerves.

Had the doctors taken notice of the clinical findings, and the history of symptoms in both legs, and arranged an MRI scan, she would have been reviewed urgently by the neurosurgical team and decompression surgery would have likely taken place within 24 hours.

The defendant trust defended the claim and denied that, at any stage, C experienced true symptoms of cauda equina syndrome. The case proceeded towards a trial on liability.

Expert neurosurgeons were consulted by each party and agreed that earlier surgery would have avoided severe symptoms of bladder and bowel dysfunction, and left-sided foot drop.

Shortly, before the trial on liability, an out of court settlement was agreed at £150,000, half of which gave C compensation for her injuries and past financial losses, and the remaining half was for future financial losses including care, orthotics, aids and equipment, physiotherapy, adaptations to property, and psychological therapy.

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Case settled by

Christine Brown

Senior Solicitor

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