From Back Pain to Paralysis - What Courts Say About Medical Negligence in Missed or Delayed Diagnosis of Cauda Equina Syndrome

1) Overview

Cauda Equina Syndrome (“CES” for short) is a serious and time-sensitive spinal cord emergency. It occurs when the nerve roots at the base of the spinal cord (the "cauda equina" nerves) become compressed, typically from a herniated disc, spinal stenosis, tumour, infection, or trauma.

As the cauda equina nerves are compressed, they suffer damage. Because damage to the nerves in the spinal cord is usually permanent, it is essential that healthcare providers such as nurses and ER physicians recognize the red-flag symptoms of CES early and take urgent action, typically consisting of imaging (usually MRI) and surgery to decompress the nerves.

Unfortunately, when CES is not diagnosed promptly, patients are usually left with permanent and life-altering impairments, including bladder and bowel dysfunction, sexual dysfunction, neurological impairments in the lower limbs often requiring assistive devices, loss of sensation, and chronic nerve pain in the saddle area and lower extremities.

In Ontario and across Canada, delayed or missed diagnosis of CES is one of the most frequent and high-stakes medical-malpractice scenarios in spinal care. Patients who present with red-flag symptoms can expect urgent evaluation; where that doesn’t happen, courts may find healthcare providers breached the standard of care.

2) Red Flag Symptoms

While every case is different, the following symptoms are often referenced in the literature and case law as being “red flags” for CES being high on the differential diagnosis.

• New or worsening bilateral leg pain or weakness (both legs)
• Saddle-area numbness or tingling (in the groin, inner thighs, buttocks)
• Loss of bladder control or new urinary retention (e.g., difficulty starting urination, overflow incontinence)
• Loss of bowel control or new onset of fecal incontinence
• Foot drop or new weakness of the legs or ankles
• Severe back pain that is sudden in onset (especially if with the above)

Because CES progresses rapidly, any suspicion of these symptoms should prompt immediate seeking of emergency care and urgent MRI/imaging.

3) What Have Courts Said About the Standard of Care in Diagnosing CES?

Canadian courts have repeatedly emphasised that when a patient presents with red-flag symptoms for CES, health-care professionals must act promptly, namely: assess the neurological signs, document saddle sensation and bladder/bowel function, and if it is indicated, order urgent MRI and refer to neurosurgery if necessary. Some key decisions:

• Williams v. Rosenstock, 2020 ABQB 303— An Alberta Court found an emergency physician breached the standard of care by failing to properly assess and diagnose CES in a timely manner when the patient was experiencing severe low back and abdominal pain, leg pain, and urinary urgency/frequency. The decision to discharge the patient was not responsive to the risk, given the red-flag nature of her symptoms.
• Chrysostom v. Kempenaar, 2023 ONSC 3664— The Ontario Superior Court found two emergency physicians breached the standard of care for failing to ask the patient about saddle area numbness when she presented with some other red-flag symptoms. Because the patient had reported saddle numbness to the triage nurse, it was reasonable to assume she would have told the ER physicians about this symptom if she was asked.

The patient in Chrysostom had been suffering sciatica 2 weeks earlier, and the defendant physicians in this case believed that her symptoms were related to this, and not CES, which led to her discharge.

In both of these cases, the Court found that if CES had been appropriately suspected, emergency imaging would have been ordered and follow up with an orthopaedic or neuro surgeon would have occurred.  

Key Takeaways from Case Law

• Providers must ask direct questions about saddle-area numbness and bladder/bowel dysfunction when patients report back pain plus leg symptoms.
• When red-flag features are present, providers must order urgent MRI and escalate rapidly to avoid permanent damage.
• Causation must be established: plaintiffs must show that earlier intervention more likely than not would have improved their outcome.
• Pre-existing spinal conditions do not remove the duty to act promptly on new or worsening symptoms.

4) Compensation for spinal cord injuries

Patients who suffer spinal cord injuries can recover damages in the form of compensation for pain & suffering (often called “general” or “non-pecuniary damages”) as well as for past and future economic loss, including lost wages if the plaintiff has been or is unable to work, the cost of future therapies, and housekeeping. Their close loved ones can claim damages as well, which include the loss of the care, guidance, and companionship of the injured person, and the value of services they now have to provide.  

When claiming for economic loss on behalf of an injured client, experienced medical malpractice lawyers should explore every avenue and ensure that any settlement reached in advance of trial fairly reflects the loss in light of the established legal principles of what can be recovered.

In May 2025, Bogoroch & Associates LLP secured a multi-million settlement for a former executive at the peak of his career, whose life was shattered by a catastrophic surgical error during spinal surgery. This patient was left permanently disabled when his nerve roots were transected (cut), causing him to lose the ability to work and requiring lifelong care.  Multidisciplinary expert evidence confirmed the profound, irreversible impact on his physical, psychological, and professional life.  The settlement provided excellent compensation for the loss of his independence, career trajectory, and quality of life, reflecting the devastating scale of the harm he suffered. While every case is different, damages in a case of undiagnosed CES may be similar, as the long-term harm caused by CES is also a spinal cord injury.  

Final Thoughts

Cauda equina syndrome is a medical emergency where timing and recognition are critical. Courts in Canada are clear: when red-flag symptoms appear, healthcare providers must act promptly. If you or a loved one have suffered damages as a result of missed or delayed diagnosis of CES, we’d be honoured to help. Please call or email Bogoroch & Associates LLP for a free consultation.