Greg Vigna, MD, JD: Cauda Equina Syndrome Deserves Comprehensive Rehabilitation

04/12/2013 // Concord, CA, USA // LifeCare123 // Greg A. Vigna M.D., J.D. // (press release)

(Catastrophic Injury Law Firm News)

Medical Perspective:

The caudal equina refers to the nerves that continue down the spinal canal after the spinal cord ends at lumbar levels L1-2. These nerves control motor and sensory function of the lower extremity and provide motor and sensory function to the organs of the pelvis including the bladder. Cauda equina syndrome refers to the set of neurologic deficits that effect motor and sensory function to the lower extremities and the bladder that occurs when there is compression of the nerve roots of the caudal equina. Causes of cauda equina compression include significant trauma to the pelvis and lumbar spine from motor vehicle crashes, gun shot wounds, and falls as well as massive herniated discs of the lumbar-sacral spine. Medical causes of cauda equina syndrome include infection, tumors, and bleeding. Symptoms will include severe low back pain, saddle anesthesia (can’t feel the area of the body that you would sit on if on a horse), acute urinary retention causing significant discomfort or incontinence, and incontinence of bowel. Management of acute cauda equina syndrome is considered a surgical emergency with best outcomes if performed within 48 hours from the onset.

The motor and sensory deficits, bowel and bladder deficits, and pain pattern for each patient is quite diverse and will require a multidisciplinary approach to rehabilitation involving multiple healthcare professionals provided in a coordinated fashion individualized to the particular needs of a patient. Motor deficients are generally asymmetric and range from significant weakness that greatly impairs ambulation requiring extensive bracing to support a flaccid lower extremity to minimal motor deficits with very minimal little impact on gait (walking). The effect on bladder function is again very diverse ranging from minimal impairment, to continuous leaking with a bladder that doesn’t store urine, or to profound urinary retention with no leaking. The only way to classify the bladder dysfunction is by urodynamic testing and future management decisions should be made by a uroneurologist based on this test. Bowel dysfunction is very difficult to manage because incontinence of stool is very common because the anus often looses its tone and simply cannot hold stool. Constant leaking of stool is not uncommon. Sexual dysfunction is also common as well as severe neuropathic pain. Sensory deficits are often present then predispose these patients to decubitus ulcers especially in areas of pressure exposed when sitting and foot ulcers from a lack of sensation. As with other catastrophic injuries there are often associated injuries such as head trauma, abdominal injuries, and fractures.

The treatment team should consist of physical therapist, who are necessary to assist with ambulation training. Orthotists are often required to fabricate braces to support flaccid extremities allowing for gait, understanding that braces can cause skin breakdown in a patient with sensation deficits. Uroneurologists are necessary for the management of the resultant neurogenic bladder, interpreting urodynamics, and optimizing medical management related to sexual dysfunction. Psychologists are necessary for individualized therapy, family therapy, and pain management. The physiatrist plays a central role in the management of these patients. The physiatrist will manage all issues related to pain, bowel dysfunction, bladder dysfunction with the input of a uroneurologist, and coordinate care with the physical therapy and psychologic services to achieve the most optimum outcome both physically, functionally, and emotionally. These patients will have multiple issues that will require long term follow up and care involving multiple physician specialties and require multiple medical providers including physical therapy and psychologic counseling.

From my experience of managing patients with cauda equina syndrome it is my opinion that nearly all of these patients will benefit from acute rehabilitation at a facility with expertise in management of these patients. The physical deficits, pain syndrome, and bowel and bladder deficits are simply so diverse and difficult to characterize that a patient who is ‘deemed’ by an insurance company or other payer source not to require acute rehabilitation should be carefully scrutinized. Nothing in my experience displays this more than a patient I cared for seeing for the first time as an outpatient who suffered a massive S1 central herniated disc that spared nearly all of this young man’s lower extremity strength. He had decompressive surgery, minimal pain following surgery, and was able to walk well. His insurance denied inpatient rehabilitation because he was ‘so functional.’ His insurance failed to consider his urinary incontinence, bowel incontinence, and sexual dysfunction. I saw this young man and he had lost his job, lost his girl friend, was constantly soiling himself with both urine and stool, and was profoundly depressed. These are simply impossible issues to handle as an outpatient. This requires daily evaluation of his bowel and bladder management by a physiatrist, rehabilitation nursing, rehabilitation counseling, vocational counseling, and psychologic services to best design a management plan going forward to minimize the impact of his injury.

Life Care Planning Law Firm Perspective:

A properly constructed life care plan will serve as a guide to future medical, rehabilitation, vocational needs, and day to day needs of a catastrophically injured patient into the future to the life expectancy of the patent. One of life care planner’s roles is to be an educator or the public and that role requires him to be objective in the evaluation of the needs of the patient, not looking at insurance issues, and provide a guide that is medically necessary and appropriate for the patient. The earlier that a life care planner is involved in a cauda equina patient’s case the better. Generally, a cauda equina patient will only get one chance with acute rehabilitation and inadequate rehabilitation in terms of length of stay and quality of care can make a big difference in outcomes and decreasing complications in the future. Further, these patients after their decompressive surgeries may be quite functional in terms of walking and self care but have significant pain issues, sexual dysfunction, incontinence of bowel and bladder, and other barriers to overcome regarding return to employment. These are complicated issues that require a comprehensive inpatient rehabilitation program that can identify issues, work on a treatment plan, and plan for post-discharge care.

A life care plan is best devised by a medical professional who is a Certified Life Care Planner with clinical experience in the care of patients with cauda equina syndrome. These patients have a great diversity in their needs which may be few to plan that is very complex. The present and future needs will be based on a clinical interview of the patient and family, review of the medical records, a psychological assessment (in some, not all cases), and communications with the treating physicians and other medical providers. Utilizing this information, the life care planner will follow specific methodologies based on published standards that are subject to peer review to devise a comprehensive plan. A properly provided life care plan should provide a road map for the care of these patients to maximize function, reduce or eliminate complications, and improve the individual’s quality of life going forward.

Lawyer Perspective:

Damages in a cauda equina patient have ranged from very little to the most significant. Several factors are the driving factors, including the permanence of injury and the needs for future care. Past and future economic (lost wages, medical expenses, medical care) and past and future noneconomic damages (pain and suffering) need to be carefully mapped out by a qualified team of litigators who specialize in spinal cord injuries and cauda equina injury. Future medical needs can be a major component because a person who suffers a cauda equina injury caused by the negligence, carelessness (negligence) or wrongdoing of another has a right to recovery for everything that has a reasonable rehabilitative probability. A life care planner and medical specialist trained in the management of the care with cauda equina injuries will be needed to provide the medical foundation to prove these damages in the future. It is essential that a patient receive the best care possible to prevent these unlikely future complications; they will not be compensated for anything that occurs after the judgment or settlement. There is often a significant vocational impact on these patients which may cause permanence in wage loss or loss of earning capacity. These cost will be discussed in detail by a vocational counselor in well-designed life care plan and serve as evidence of damages to the court.

A serious injury lawyer must provide a medical foundation for future costs related to a catastrophic injury for a patient to receive a full judgment for their damages. Failure to take into account costs related to sexual dysfunction, chronic pain, future medical, and future care cost as a patient ages with this disability will lead to inadequate compensation. Sexual dysfunction, bladder, and bowel incontinence are also evidence of pain and suffering that can be separately awarded at the jury’s discretion. Pain and suffering is defined as “physical pain/mental suffering/loss of enjoyment of life/disfigurement/physical impairment/inconvenience/grief/anxiety/humiliation/emotional distress.” Sexual dysfunction will also be a basis for a loss of consortium claim by the uninjured spouse against the negligent party, whereby the spouse is suing for the ‘deprivation of the benefits of a family relationship’ which would include sexual relationships. Loss of consortium is defined as “1. The loss of love, companionship, comfort, care, assistance, protection, affection, society, and moral support; and 2. The loss of the enjoyment of sexual relations [or the ability to have children].”

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