Examination for Back Pain must be Thorough

[Badri]

Mr. B, a 42 year old builder, saw his family doctor with a 3 week history of back pain radiating down the left leg. Dr. S his GP found nothing of concern when he examined him. He then prescribed Ibuprofen and referred him for physiotherapy. Over the next few weeks the pain increased and the patient required diclofenac and cocodamol to control the pain.

Two months later while still waiting for physiotherapy, the pain got so severe that he called for an ambulance which took him to the local hospital. He was examined by the doctor at the Emergency Department. The doctor noted slight left foot drop and bilateral SLR of 45 degrees. The doctor did not do a proper examination of his neurology. He thought the patient had simple back pain made worse by moving his legs. He was sent home on diazepam.

A week later the back pain was worse with intermittent numbness in both buttocks. Mr B called the GP emergency service. Mr B told the doctor who came to see him that he could pass only small amounts of urine and the back pain was much worse. The doctor examined him briefly and noted no saddle anaesthesia. He prescribed tramadol and advised him to see his own doctor the next day.

His G.P. examined him briefly the next day and wrote in his notes, “no red flags”, no loss of bladder or bowel function and no saddle anaesthesia. He gave Mr B an injection of dyclofenac and arranged for an MRI scan to be done. It was not an emergency scan.

Two days later, as the pain became unbearable, Mr B called for an ambulance and went to the Emergency Department. On the way he became incontinent. On admission he had an emergency scan which showed a large central disc prolapse at L4/L5 level pressing on the cauda equina. Surgical decompression of the disc was done the next day. Following surgery he was noted to have bilateral foot drop. He also had bowel, bladder and sexual dysfunction.

Mr. B brought a claim against all the doctors involved. He claimed that no proper history was taken and the examination was not thorough. The perianal sensation and anal tone was never checked and that he was not referred for urgent assessment.

My Comment: The notes made by the doctors indicate that not everything was normal. The emergency dept. doctor writes "slight left foot drop" What does that mean? At one stage patient complains that he can pass only little amounts of urine. Was this retention with overflow? They write no anaesthesia in saddle area. Was the area checked properly?

Whenever someone complains of severe back pain, it is important to do a thorough neurological examination. Sometimes it can be difficult to test for motor power. Sensation however can be checked accurately. It is important to test for light touch and pin prick sensation around the perineum. The anal tone can be checked easily and should be recorded in the notes.

The Experts Opinion: The examinations conducted by all the doctors were substandard. The assessment by the Emergency Department doctor was also inadequate and the experts were critical of the delay before decompression was done. Earlier treatment would have prevented all the neurological complications that followed. The case had to be settled for a high sum shared equally by the family doctors and the hospital.

(This case was reported in the Case Book of the MPS this month)

[uamohammed]

Hi Badri
This is really shocking to know the pathetic way a suffering patient was treated. When you see a patient for the first pain with back pain you may not order for a scan, but you should examine him properly because apart from intervertebral disc abnormality it might be a forerunner of many other diseases including internal malignancy with metastasis or cold abscess. Even after seeing the foot drop which was enough to get alerted, he was shabbily treated. I believe that this incident took place in UK or some western country from the different tiers of medical fraternity which you describe here. If it is in Indian conditions, where doctors in Govt. Hospitals are over-worked with meagre facilities, this can be excused.
Incidentally I remember your note in reply to one of my articles (Medicine in bygone days) that you as a house surgeon saw in our GH treating bronchial asthma patients with parenteral adrenaline without even measuring blood pressure. That was more than fifty years ago. Since I had worked in GH casualty more than some of you because of my senior house-surgeoncy and postgraduate graduate study in medicine in the same institution, I know the working of the casualty a little better. There were so many coolie patients who suffered from chronic bronchial asthma and who used to live on foot paths in and around George Town. And many of them had become addicted to adrenaline injections and if they were not given adrenaline when they come with an acute episode, they would not go away at all. So house surgeons and junior doctors used to write for adrenaline or some other injections. That was the reason for the callous way doctors treated some of their patients. But otherwise I remember so many cases where junior doctors treated a number of patients in a remarkable way.
I recall this half a century old incidents in an overcrowded hospital and in an underdeveloped country when you presented an awkward incident that had taken place in a most advanced set up.

UA Mohammed

[Badri]

Mohammed,
It is true. This was a case reported in UK where the health care is considered as one of the best in the world! So you see even in places considered as excellent for medical care of ordinary people, this type of carelessness can occur. I do not know how the poor in India get treated as it is a long time since I have been to a Govt. Hospital in India.

[uamohammed]

HI Badri

Man is man wherever he is. Does not matter whether in UK or in a remote Indian village. The facilities may be different. It depends upon your background which governs your consciousness. You remember our teachers, most of them were devout professionals. I remember my chief, Dr K R,who used to see each one in the ward with utmost care. You can see modern medical professionals are equipped with latest gadgets which if judiciously used might benefit the patients. But what we witness most of the time is that the patients are exploited too much, in the process they are put into unnecessary investigations and procedures without actually benefiting them.

UA Mohammed