Misdiagnosed Cauda Equina Syndrome Leads to Permanent Neurological Sequelae

This case study examines a missed diagnosis of Cauda Equina Syndrome in a pediatric patient, highlighting the importance of thorough diagnostic procedures and timely intervention.

ByWendy Ketner, M.D.

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Published on January 30, 2024

MRI of vertebral section

Case Overview

This case study involves an individual who initially experienced severe back pain, which was misdiagnosed as a muscle injury and later as low back pain with bilateral lumbar radiculopathy. The patient first felt a sharp pain accompanied by a popping sound while bending over. Despite taking Flexeril, the pain persisted, leading to her dismissal from work due to discomfort. Four days later, the patient's condition worsened, resulting in urinary incontinence.

Upon visiting the emergency department, the patient was noted to be in extreme distress, exhibiting symptoms such as constipation, back pain, numbness, and increasing leg pain. Despite these symptoms, only a plain X-ray was conducted instead of a CT scan. The X-ray showed mild facet arthropathy but was otherwise deemed normal.

The patient's primary care pediatrician was consulted the following day. The physician noted additional symptoms including difficulty walking and constant pain. Given the severity of the symptoms and their persistence over six days without bowel movement, an MRI was ordered for two days later. In the interim, the patient was advised to return to the ER if conditions worsened.

The MRI revealed multilevel disc extrusions causing bilateral recess stenosis at L5-S1 and right L4-L5. This led to an emergent surgery involving bilateral laminectomy from L3-S1, an L4-L5 discectomy, and an L5-S1 discectomy. The diagnosis was cauda equina syndrome, a serious neurological condition that can lead to permanent paralysis if not treated promptly.

Questions to the Pediatrics expert and their responses

Q1

How often do you see teenagers with back pain along with radiating symptoms associated with incontinence?

As a board-certified pediatrician with 20 years of experience, I encounter such cases infrequently, perhaps once every two years.

Q2

Generally, when a teenager comes in with back pain along with radiating symptoms associated with incontinence, what are the next appropriate steps from a pediatrician?

Any significant neurologic symptoms, especially those associated with incontinence, warrant an immediate MRI and neurosurgical evaluation.

Q3

Have you ever reviewed a similar case? If yes, please elaborate.

Yes, I have reviewed two similar cases. This case is clearly a breach of the standard of care at every level, except for the decision to bring her to the OR emergently.

About the expert

This expert is a board-certified pediatrician with two decades of experience, including significant roles in pediatric research and academia. They have held leadership positions at renowned medical centers and currently serve as an assistant clinical professor of pediatrics at three medical schools. Their extensive background in pediatric care, coupled with their active involvement in the American Academy of Pediatrics, makes them highly qualified to provide expert insights into this case involving a teenager's misdiagnosed neurological condition.

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About the author

Wendy Ketner, M.D.

Wendy Ketner, M.D.

Dr. Wendy Ketner is a distinguished medical professional with a comprehensive background in surgery and medical research. Currently serving as the Senior Vice President of Medical Affairs at the Expert Institute, she plays a pivotal role in overseeing the organization's most important client relationships. Dr. Ketner's extensive surgical training was completed at Mount Sinai Beth Israel, where she gained hands-on experience in various general surgery procedures, including hernia repairs, cholecystectomies, appendectomies, mastectomies for breast cancer, breast reconstruction, surgical oncology, vascular surgery, and colorectal surgery. She also provided care in the surgical intensive care unit.

Her research interests have focused on post-mastectomy reconstruction and the surgical treatment of gastric cancer, including co-authoring a textbook chapter on the subject. Additionally, she has contributed to research on the percutaneous delivery of stem cells following myocardial infarction.

Dr. Ketner's educational background includes a Bachelor's degree from Yale University in Latin American Studies and a Doctor of Medicine (M.D.) from SUNY Downstate College of Medicine. Moreover, she is a member of the Board of Advisors for Opollo Technologies, a fintech healthcare AI company, contributing her medical expertise to enhance healthcare technology solutions. Her role at Expert Institute involves leveraging her medical knowledge to provide insights into legal cases, underscoring her unique blend of medical and legal acumen.

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