These cases are to get you to start thinking and questioning your knowledge around the topic of spine for everyone. The full cases, case takeaway videos, recoding of the webinar and RCS CPD certificate (2hours) can be found here.
Previous left L45 microdiscectomy age 31 for unilateral sciatica.
Hx of VTE – post-partum DVT 10 yrs ago and PE 5 years ago - on lifelong warfarin.
Hx of depression and anxiety. Normal BMI
Longstanding intermittent low back pain since her discectomy, normally self-limiting.
Pain more persistent over the last 2 years
Worse over the last 2 weeks radiating to both buttocks – has been taking lots of codeine
Calls an ambulance at 02:05am on a Sunday morning suffering with severe back and bilateral buttock pain, inability to open bowels for 1 week, difficulty passing urine for 48 hours and one episode of urinary incontinence at midnight.
Assessment by ED doctor:
Patient in pain lying on trolley with hips and knees flexed. Difficult to examine due to pain.
Can straighten legs but only one at a time.
Any attempt at passive straight leg raise causes pain in the lower back.
Patient not able to sit or stand due to pain in lower back. Denies leg pain.
Tone – hard to assess but seems normal
Sensation - L1 to S1 normal bilaterally.
Motor – Normal across both ankles 5/5. Hard to assess proximally due to pain
Reflexes – Left TA (ankle jerk) seems absent but otherwise normal
Can discriminate sharp and blunt sensation bilaterally S2 to S5.
Anal tone normal
Able to voluntarily contract external sphincter.
Hard stool in rectum.
Rightly or wrongly, the ED doctor carries out a bladder scan. This shows 440mls of urine. She doesn’t feel she has a full bladder but she’s in a lot of pain, which makes it hard to assess.
Morning comes. She got admitted overnight and she’s seen on the post-take wardround.
She is much more comfortable with the analgesia
In this case an MRI scan was booked, which demonstrated a large central disc occupying the spinal canal. Repeat PR exam still shows sensation to be intact and she has some voluntary squeeze also.
Case 2 - lower back pain
42 yearr old male with a longstanding history of low back pain, on and off. Recently it has been more persistent and he now has buttock pain.
His symptoms are worst in morning and after sitting. Positive tension signs in both legs affecting L5.
His GP kindly arranged a scan
A diagnosis is made from the CT
Case 3 - spinal fracture
17 year-old male cyclist struck by car. Complaining of neck pain and inability to move upper and lower limbs. Imaging obtained is shown below
On examination he is GCS 15, the airway is patent and cervical spine immobilised. He is ventilating well. RR 20, normotensive and haemodynamically stable.
He has a flicker of movement deltoid and biceps, but no lower limb motor function. A sensory level at C5. Priapism
Decreased anal tone with present but altered perianal sensibility
Case 4 - chronic pain
45 year old lady with a chronic history of neck and upper back pain
PMHx: Anxiety / depression – stressed at work. Poor body image because of acne
On examination there is loss of cervical lordosis. Tight paravertebral muscles. A few areas of tenderness C5/6
She had osteopathy, physio, Pilates and Chiro – no improvement
Steroid injection - gave some mild, temporary relief
She remains unhappy and struggling at work
Please post your thoughts about these cases in the comments section below.
The full cases, case takeaway videos, recoding of the webinar and RCS CPD certificate (2hours) can be found here
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