This case involves a woman who presented to her chiropractor with severe lower back pain and numbness in her bilateral lower extremities. The chiropractor performed a manipulation on the woman and sent her home. The woman continued to experience pain for a few days before deciding to visit the hospital. She was ultimately diagnosed with cauda equina syndrome and as a result, she suffers from permanent difficulty walking. A chiropractor was sought to opine on the standard of care for patients who present with these symptoms.
Question(s) For Expert Witness
- 1. What is the role of the chiropractor in terms of appropriate referral and/or emergent treatment with this presentation?
Expert Witness Response E-136503
Symptomatic cauda equina syndrome is a fairly rare beast, which I’m very familiar with and actually lecture on in my advanced lumbar differential diagnosis class. There are classic warning signs that mandate a referral to the emergency room including 1) urinary symptoms such as hesitancy and incontinence, 2) severe bilateral lower extremity pain with or without neurological findings on exam, and 3) paresthesia/causalgia/dysesthesia in the perineal region. The number one cause of cauda equina syndrome is an injury to the S3 nerve root, secondary to a large central disc herniation at L4 or L5. It can also occur secondary to an inflammatory reaction of the pia mater of the nerve roots of the cauda equina. Epidural injections have been associated with the development of cauda equina syndrome via the arachnoiditis route as well.
Expert Witness Response E-136505
Bilateral numbness in the lower extremities is not a common presentation and when present requires proceeding with caution. Though I would need to see what details may have emerged on physical exam or history, spinal manipulation was in all likelihood unwarranted lacking a specific diagnosis. I instruct my students that presentation with possible cauda equina syndrome warrants immediate referral for possible decompression within 24 hours to mitigate the risk of possible irreversible neurological damage. That is, without a doubt, the standard of care. Manipulation was likely contraindicated without an imaging study.