Gardner Syndrome Case Study

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Gardner Syndrome Case Study



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Gardener Syndrome

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Gardner enjoyed litigation and the development of trial strategy but was otherwise bored by legal practice. In his spare time, he began writing for pulp magazines. His first story was published in He created many series characters for the pulps, including the ingenious Lester Leith, a parody of the "gentleman thief" in the tradition of A. Raffles ; and Ken Corning, crusading lawyer, crime sleuth, and archetype for his most successful creation, Perry Mason.

While the Perry Mason novels seldom delved deeply into characters' lives, the novels were rich in plot detail which was reality-based and drawn from his own experience. Under the pen name A. Fair, Gardner wrote a series of novels about the private detective firm of Cool and Lam. In another series, district attorney Doug Selby litigated against attorney Alphonse Baker Carr in an inversion of the Perry Mason scenario. Prosecutor Selby is portrayed as a courageous and imaginative crime solver; his antagonist A. Carr is a wily shyster whose clients are invariably "as guilty as hell". Much of that story is set at the historic Pierpont Inn near his law office. With the success of the Mason series, more than 80 novels, Gardner gradually reduced his contributions to the pulp magazines until the medium died in the s.

Thereafter, he published a few short stories in the "glossies", such as Collier's , Sports Afield , and Look , [10] but most of his postwar magazine contributions were nonfiction articles on travel, Western history, and forensic science. Gardner's readership was a broad and international one, and included the English novelist Evelyn Waugh , who in called Gardner the best living American writer. Gardner also created characters for various radio programs, including Christopher London , starring Glenn Ford , and A Life in Your Hands — Burr had auditioned for the role of the district attorney Hamilton Burger , but Gardner reportedly declared he was the embodiment of Perry Mason. He had a lifelong fascination with Baja California and wrote a series of nonfiction travel accounts describing his extensive explorations of the peninsula by boat, truck, airplane, and helicopter.

Gardner devoted thousands of hours to "The Court of Last Resort", in collaboration with his many friends in the forensic, legal, and investigative communities. The project sought to review, and when appropriate, reverse miscarriages of justice against criminal defendants who had been convicted because of poor legal representation, abuse, misinterpretation of forensic evidence, or careless or malicious actions of police or prosecutors. Gardner and his wife separated in the early s, but did not divorce, and in fact their marriage lasted 56 years, until Natalie's death in Gardner's widow died in , aged , in San Diego.

She was a member of Jehovah's Witnesses. She was survived by her brother, Norman Walter. Gardner died of cancer diagnosed in the late s [19] on March 11, , at his ranch in Temecula [6] [20] —the best-selling American writer of the 20th century at the time of his death. Gardner was cremated and his ashes scattered over his beloved Baja California peninsula. From to , the Ransom Center featured a full-scale reproduction of Gardner's study that displayed original furnishings, personal memorabilia, and artifacts.

Written in as the second entry in the Cool and Lam series, the book was rejected at the time by Gardner's publisher. An unspecified article Gardner wrote for True magazine is referenced by William S. Burroughs in his novel, Naked Lunch. Gardner's name is well known among avid crossword puzzle solvers, because his first name contains an unusual series of common letters , starting and ending with the most common letter of the English alphabet , and because few other famous people have that name.

As of January , he is noted for having the highest ratio 5. The minute program is available as a VHS videorecording. From Wikipedia, the free encyclopedia. American writer and lawyer. Natalie Frances Talbert. Agnes Jean Bethell. Main article: Erle Stanley Gardner bibliography. New England Historic Genealogical Society. Archived from the original on 1 August Retrieved 4 August ISBN Retrieved 1 August Encyclopedia Britannica. Retrieved The New York Times. As the best-selling American author of the century, Erle Stanley Gardner often insisted that he was 'not really a writer at all,' and to be sure, there were many critics who enthusiastically agreed with him.

But millions of readers who have bought more than million copies of his books in American editions alone, looked upon Mr. Gardner, creator of the redoubtable defense lawyer Perry Mason, as a master storyteller. Kingston March 31, Kirkus Reviews. Retrieved February 18, Archived from the original on Evelyn Waugh: The Later Years — As discussed above there is a balance of evidence in favour of decompressive surgery within 48 h of the onset of CES with some series showing additional benefit if that window is reduced to 24 h.

However it is also evident that patients who receive the most expeditious treatment may be left with disabling sphincter and lower limb deficits causing a degree of disability and dependency which quite naturally motivates them, their relatives and their lawyer to try unsuccessfully to prove negligence and obtain redress. It is also true that some patients are lucky and in spite of being designated CES-R on admission to hospital then subjected to some delays prior to surgery, they eventually have an acceptable long term outcome. On the other hand the rarity and variability of CES can result in misdiagnosis and delays by first, the patient who may have developed painless urinary retention over the previous 6—8 h and may not have raised the alarm or sought medical advice until the situation was irreversible if it was ever reversible.

Secondly, the GP or therapist may not have appreciated the gravity of the situation and consequently failed to advise immediate transfer to hospital. Thirdly, delays may occur in the hospital [ 39 ] with junior doctors and nurses not recognising the syndrome presented to them. Finally, the non-availability of out-of-hours MRI and specialist spinal surgical facilities may singly or collectively cause further delay [ 8 ] which may be critical to the eventual outcome, especially if there is evidence of progressing neurological deficit during this time.

If any of those imperfections are found to be negligent then substantial damages may be awarded. In our experience damages are more likely if the medical records are deficient with a lack of crucial clinical detail including recordings, with times, of neurological deficits and any changes in bladder function. As mentioned above CES, although rare, figures large in terms of medico-legal costs:. Just under half the 62 cases notified related to general practice involving incorrect or delayed diagnosis, the rest were almost all orthopaedic concerning inadequate treatment or post-operative complications [ 28 ].

Of the 78 notified claims, 39 related primarily to the Orthopaedic department and 21 to Accident and Emergency with 7 to Neurology or neurosurgery. The remaining 11 related to other departments [ 42 ]. It is evident that CES occupies a prominent position in the medico-legal field partly through lack of awareness and urgency in its management by all concerned, and partly because of the devastating consequences of the condition which even with the best treatment may lead to bowel, bladder, sexual and lower limb dysfunction.

It is now established that in around half of cases, the die is cast within the first 4—6 h of a severe central disc prolapse resulting in CES-R. This is invariably an impossibly short length of time in which to achieve referral to an appropriate hospital, confirmation of diagnosis by MRI scan and surgical decompression. It follows that delay until the next operating list is probably not significantly related to causation in these cases.

However, all things being equal, clinicians should aim, if at all possible, to relieve neurological compression within around 48 h of onset bearing in mind that results are probably improved by relief within 24 h or sooner especially if they have CES-I with signs of progression. Early surgery may reduce chronic sciatica [ 39 ]. Prompt diagnosis and investigation followed by timely and skilful surgery and rehabilitation are the essentials of best practice in the treatment of this rare but often very damaging condition.

It is a tragedy, sometimes avoidable, if an incomplete syndrome becomes complete while under medical supervision. Litigation is common when a patient has persistent residual symptoms [ 26 ], especially if the clinical record is defective and the likely outcome has not been fully explained and understood by the patient prior to surgical intervention. Immediately seek senior advice with a view to contacting a Spinal Surgery Team and arranging emergency MRI with transfer to a Spinal Surgery Unit if not available on site. Delay may cause further neurological damage! National Center for Biotechnology Information , U. Journal List Eur Spine J v.

Eur Spine J. Published online Dec Author information Article notes Copyright and License information Disclaimer. Alan Gardner, Email: moc. Corresponding author. This article has been cited by other articles in PMC. Abstract Cauda equina syndrome CES is a rare condition with a disproportionately high medico-legal profile. Keywords: Cauda equina syndrome, Central disc prolapse, Bilateral sciatica, Urinary retention, Perineal hypoaesthesia, Sexual dysfunction. Background CES is a rare condition with a disproportionately high medico-legal profile. Acute bladder dysfunction with a history of low back pain and sciatica.

These are: The significance of delays in diagnosis and referral to hospital. The risks and benefits of emergency versus urgent surgery. The significance of surgical delay beyond 24 and 48 h. The prognostic significance of unilateral and bilateral leg signs. The adverse effects of delay on the more robust sciatic nerve roots. The medico-legal implications of the above. The literature In order to try to clarify matters, the relevant literature has been reviewed and the essential points are described below.

In an authoritative review of the literature in [ 16 ], Gleave and Macfarlane [ 15 ] confirmed their previous views and made these important points: Those series which include CES-I patients tend to show a favourable outcome from early surgery. Summary of management of CES CES is a rare condition but may have devastating consequences for patients, their families and their clinical contacts if the condition is not adequately managed in order to avoid unpleasant clinical and legal sequelae.

Prognosis This is difficult to assess in the individual case with this complex condition as the series described above have varying diagnostic criteria and fixed points in their descriptions, however it is possible to suggest some broad generalisations based on the available information: Around half of CES cases present with CES-R at the time of admission to hospital [ 11 , 23 , 29 ]. Medico-legal considerations As discussed above there is a balance of evidence in favour of decompressive surgery within 48 h of the onset of CES with some series showing additional benefit if that window is reduced to 24 h.

Conclusion It is evident that CES occupies a prominent position in the medico-legal field partly through lack of awareness and urgency in its management by all concerned, and partly because of the devastating consequences of the condition which even with the best treatment may lead to bowel, bladder, sexual and lower limb dysfunction. CES-Retention: Urgent management!

May be more severe and bilateral with increased neurological deficit. Test trigone sensation—pull catheter gently Neurogenic bladder and bowel dysfunction: painless full bladder, no anal sphincter function. No trigone sensation on pulling catheter. Open in a separate window. Conflict of interest No conflicts of interest are declared. References 1. Anthony S. Cauda equina syndrome. Cauda equina syndrome secondary to lumbar disc herniation—a meta-analysis of surgical outcomes.

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Time-dependent surgical outcomes following cauda equina syndrome diagnosis—Comments on a meta-analysis. Kostuik JP. Medico-legal consequences of cauda equina syndrome: an overview. Brit Med J. Lawrentschuk N, Nguyen H. Cauda equina syndrome secondary to constipation: an uncommon occurrence. ANZ J Surg. Markham DE. Cauda equina syndrome: diagnosis, delay and litigation risk. Curr Orthop. Cauda equina syndrome: factors affecting long term function and sphincteric outcome. The indications for and results of the excision of lumbar intervertebral disc protrusions: a review of cases. Prognosis for sphincter recovery after operation for cauda equina compression owing to lumbar disc prolapse.

Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equina nerve roots. Cauda equina syndrome after induction of spinal anaesthesia. Podnar S. Epidemiology of cauda equina, conus medullaris lesions. Muscle Nerv. Qureshi A, Sell PJ. Cauda equina syndrome treated by surgical decompression: the influence of timing on surgical outcome. Pathoanatomy and pathophysiology of spinal nerve root compression. Cauda equina syndrome complicating ankylosing spondylitis: MR features. J Comput Assist Tomogr. Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Shephard RH. Diagnosis and prognosis of cauda equina syndrome produced by protrusion of lumbar disc.

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