Leading medical malpractice lawyer notes sharp rise in cauda equina cases

Neinstein’s Rose Leto identifies 'tunnel vision' phenomenon as a potential cause of delayed or missed identification of the serious neurological condition

Rose Leto, Partner at Neinstein Personal Injury Lawyers, discusses cauda equina syndrome, what may be playing a part in the rising number of cases she’s seeing in her practice, and what the firm looks for in determining whether or not there is legal recourse for a client.

What is cauda equina syndrome?

Cauda equina syndrome is a serious neurological condition where early identification and treatment is crucial in order to avoid potentially life changing devastating effects.

At the bottom of our spinal cord are a collection of nerves called the cauda equina (named after its resemblance to a horse’s tail). Cauda equina syndrome that occurs there is a compression of those nerves.

The clinical diagnosis of cauda equina syndrome is made through a thorough history and physical exam and is confirmed with radiographic studies. It is accompanied by a range of symptoms that can vary in severity based on the degree of compression and the nerve root that is being compressed. “Red flag” symptoms that health care practitioners need to assess for are:

  • Bladder retention and/or incontinence;
  • Bowel disturbance/incontinence;
  • Saddle Anesthesia – numbness or different sensations in the backs of your legs, butt, hip, groin and inner thighs;
  • Pain in your back and/or legs;
  • Urinary and /or fecal incontinence; and
  • Weakness or paralysis with your legs.

Once a red flag symptom is identified, immediate and follow-up imaging is required because cauda equina syndrome is a serious and emergent diagnosis. Once cauda equina syndrome is identified on imaging, immediate surgical intervention is required. A failure to quickly refer or treat a patient presenting with signs of cauda equina syndrome can have serious consequences, including paralysis, incontinence and impaired mobility.

What are the facts at issue and/or the most challenging aspects of cauda equina cases? How do they compare to other types of medical malpractice that you handle?

Cases involving cauda equina syndrome are complex. As in all medical malpractice cases, we must prove the following:

1. There has been a breach in the standard of care expected of a reasonable physician. In Ontario, we do not hold physicians to a standard of perfection, but we do require them to act reasonably and in accordance with their expertise. In the case of cauda equina syndrome, breaches of standard of care are typically centered around a failure to recognize or assess the red flag symptoms and/or a delay in obtaining the appropriate follow-up testing and treatment once cauda equina syndrome is suspected. Additional issues we assess for are the failure to communicate between practitioners, the use of referral or external consultation, and other hospital-system issues.

2. The breach in the standard of care caused or contributed to the plaintiff’s injuries. Proving a breach in the standard of care is not enough. This is what we refer to as causation. In the case of cauda equina, the defense tends to raise two arguments with respect to causation: That there is little time for physicians to treat symptoms before they are irreversible, or that once a patient has the “red flag” symptoms, it is already too late. It is of the utmost importance to retain strong and experienced experts to comment on these issues, as well as to keep informed of the relevant medical literature.

3. The Plaintiff suffered compensable damages caused by the breach. This can include pain and suffering, loss of income, costs for medical treatment or future care costs. Patients who develop cauda equina syndrome have almost always had some form of prior problem with that area of the spine. Therefore, when we are assessing damages for our client, we must consider any pre-existing problems that may have manifested even absent the negligence.

In your experience, would you say cauda equine cases are becoming more common? If so, to what do you attribute this upward trend?

Unfortunately, we have recently seen an increase in cauda equina cases. This is unfortunate as cauda equina syndrome is a true medical emergency with signs that should not be missed.

We have noticed a trend where the patient has had multiple attendances to the emergency department before they are eventually diagnosed. It is possible that the “tunnel vision” phenomenon has a part to play: healthcare practitioners become falsely reassured by the assessments—sometimes incomplete or incorrect—of their colleagues. In these cases, we believe that there is legal recourse.

While it is difficult to discern the reason for the upward trend, it is important to recognize that healthcare is delivered through collaboration and a team-based environment. Any failure in communication or even in the exercise of clinical judgment has ripple effects. At Neinstein Personal Injury Lawyers, we believe that injured patients should not be left to bear the consequences of these errors.


Rose Leto is a Partner at Neinstein Personal Injury Lawyers LLP. She focuses on personal injury and complex medical malpractice litigation. Rose is known for her thorough and robust advocacy and skillful negotiation. As an integral member of the leadership team at Neinstein, Rose is responsible for the firm's practice innovation. She provides direction for all lawyers and staff members at the firm and is a source of knowledge and trust amongst her peers.

Rose is well-known as a thorough and diligent lawyer, ensuring that her clients' cases are advanced with the utmost care and consideration. Rose is currently spearheading a proposed class action lawsuit against Long Term Care Provider, Chartwell, for alleged failures in their outbreak planning and response to COVID-19. For more information, read about the Chartwell class action.