Disc herniations in the neck or back may result from trauma, such as a car accident, or from underlying degenerative disc disease. Most disc herniations cause pain and require treatment. In meeting with clients about the consequences of disc herniation, attorneys must keep in mind that some herniations are far more serious than others. One consequence of this is that a physician who meets a patient with signs and symptoms of spinal nerve root compression is obligated to listen carefully to the history and take steps to diagnose and treat the problem before serious, permanent deficits become unavoidable.
The discs between our vertebrae are comprised of a semi-solid gelatinous central portion (the nucleus propulsus) and a tougher fibrous outer layer (the annulus fibrosis). The discs are near nerve roots that exit the spinal cord and enervate various parts of the body. With aging and/or trauma, the annulus can rupture, allowing the nucleus propulsus to protrude. This condition is known as a disc herniation. When disc herniation occurs, it can compress and damage the nerve roots. The posterior portion of the discs in the lumbar spine are reinforced by the posterior longitudinal ligament, which may compress posteriorly herniated nucleus propulsus against the lumbar nerve roots.
Nerve Root Compression
Herniated discs which compress nerve roots can cause profound neurologic damage, including severe motor and sensory loss. Nerve root compression results in distinctive signs and symptoms that can be traced to the intervertebral level of the compressed nerve root. Patients may report radiating pain, sensory loss and weakness, and may exhibit reduction in or loss of reflexes.
Nerve root compression can range from mild to severe. Mild nerve root compression may not require surgical treatment and may be appropriately treated with medications and other conservative measures. Nerve root compression that is severe enough to cause weakness in the arms or legs requires prompt diagnosis and surgical treatment because compression leads to death of the nerve cells and can permanently affect the function of the sensory and motor nerves downstream from the point of compression.
Left untreated, patients with cervical nerve root compression can lose function in an affected arm. With large disc herniations in the lumbar spine, several nerve roots can be affected. Bilateral radiating pain into the legs, extensive weakness and sensory loss, and a loss of bowel and bladder function is called cauda equina syndrome. Patients with cauda equina syndrome can suffer great loss of function, including the ability to walk, to urinate, to defecate normally, and the loss of genital sensation.
Medical Standards of Care–Diagnosis
In order to determine whether a client has a potential claim against a physician for failure to diagnose and treat nerve root compression, it is important to know the applicable medical standard of care. When patients with nerve root compression present to a medical care provider, a thorough history and neurologic examination must be performed. Such patients most commonly present to primary care physicians or at emergency rooms because typically the onset of symptoms is dramatic following the herniation of the disc. When a patient complains of neck or back pain and any problems with their arms or legs, the physician should ask if he has numbness, tingling, or loss of strength of function in the arms (if neck pain) or legs (if low back pain). With low back pain and radiating symptoms in the legs, the patient should be asked if he is experiencing any bowel/bladder changes (either retention or incontinence).
The physician must perform a full neurologic exam if the patient complains of weakness and sensory loss. The examination of the patient should include sensory, strength, and reflex testing to determine whether there is evidence of neurologic dysfunction. Consideration of cauda equina syndrome requires that the physician check for “saddle anesthesia” (loss of genital/rectal sensation) and rectal sphincter muscle function. If the patient has acute radiculopathy with rapidly progressive neurologic deficits or radiculopathy with urinary retention, saddle anesthesia, or bilateral neurologic symptoms, then Magnetic Resonance Imaging (MRI) studies should be performed urgently. MRI studies are the best means of confirming when a patient has suffered a disc herniation that is causing compression.
We have represented numerous clients in cases where providers failed to diagnose and obtain treatment for such patients. Often they fail to properly listen to or examine the patient. It is surprisingly common for providers to fail to recognize the urgency of the patient’s condition and fail to obtain appropriate testing and treatment.
Medical Standards of Care–Treatment
Compression that results in serious neurologic signs and symptoms must be corrected surgically. It is generally accepted in medicine that the sooner the decompression occurs the better. The severity and duration of neurologic signs and symptoms as of the time of surgery are good predictors of what the patient’s recovery will be after surgery. If the compression is severe and left untreated for days or weeks, then the patient may have little or no recovery after surgery. If the compression is corrected quickly, before profound weakness occurs, then the patient may recover to normal or near-normal function.
In particular, the loss of bladder function in cauda equina syndrome has been well-studied. Multiple studies have demonstrated that when surgical decompression occurs within 36 hours of the onset of urinary retention, patients have a much better chance to recover bladder function. Late decompression may mean that the patient permanently loses function and will face a lifetime of catheterization.
Our firm has successfully handled many medical malpractice cases where medical care providers failed to diagnose acute nerve root compression leading to progressive loss of neurologic function. These cases require working with multiple expert witnesses to prove not only that the diagnosis should have been reached, or reached earlier, but also that earlier treatment would have allowed the patient to obtain a significantly better recovery of function. Our attorneys are always available to evaluate potential medical negligence cases.