Paul Bennet Flashcards
What does Paul’s patient profile tell us?
Paul was given a leaflet on low back pain the first time he saw his GP about it a few years ago
Works as a math teacher in a secondary school which requires him to stand for long periods of time
Likes to do yoga to relax
History of longstanding back pain managed by painkillers
Enjoys going to the theater with his partner
Has 2 Border Collies and enjoys taking them for walks
What does Paul talk about in the case video?
In hospital, came in after his lower back pain got worse and felt pins and needles in his legs
A&E gave him painkillers
Neuro exam - tested movements of arms and legs
Hasn’t urinated all day - full bladder
How can back pain be relieved?
- Stay as active as possible, try continue with daily activities (resting for long periods likely to make pain worse)
- Exercises and stretches specifically for back pain, and yoga, swimming, walking etc.
- NSAIDs = Anti-inflammatory painkillers e.g. ibuprofen
- Hot or cold compression packs for short term relief
When should back pain resolve?
When should you seek help and from who?
Usually gets better on its own within a few weeks or months
Seek help at the GP or directly from a physiotherapist
Seek help if: the pain doesn’t improve, stops you from doing daily tasks, pain is very severe or getting worse, worried about the pain and struggling to cope
What are the possible treatments for back pain from a specialist?
Group exercise classes - strengthen back muscles and improve posture
Manual therapy treatments e.g. manipulating spine and massages
Psychological support e.g. CBT to help cope with pain
What are some causes of back pain?
Often non-specific
Injury - sprain / strain
Slipped (prolapsed) disc - presses on nerve
Sciatica - irritation of the nerve running from pelvis to feet
How can back pain be prevented?
Regular back stretches and exercise Stay active Avoid sitting for long periods Take care when lifting Improve posture Good mattress support Lose weight
When is it important to get immediate advice about back pain?
When combined with other symptoms e.g.:
Numbness or tingling around your genitals or buttocks
Difficulty peeing
Loss of bladder or bowel control – peeing or pooing yourself
Chest pain
High temperature
Unintentional weight loss
Swelling or a deformity in your back
It does not improve after resting or is worse at night
It started after a serious accident, such as after a car accident
The pain is so bad you’re having problems sleeping
Pain is made worse when sneezing, coughing or pooing
Pain is coming from the top of your back, between your shoulders, rather than your lower back
What is non-specific back pain?
What are some symptoms and causes of non-specific back pain?
There is no obvious cause
Tends to get better or worse depending on your position – for example, it may feel better when sitting or lying down
Often feels worse when moving – but it’s not a good idea to avoid moving your back completely, as this can make things worse
Can develop suddenly or gradually
Is sometimes the result of poor posture or lifting something awkwardly, but often happens for no apparent reason
May be caused by a minor injury such as sprain (pulled ligament) or strain (pulled muscle)
Can be associated with feeling stressed or run down
Will usually start to get better within a few weeks
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What are different medical conditions that can cause back pain and how do they present?
Slipped disc – back pain and numbness, tingling, weakness in other parts of the body
Sciatica – pain, numbness, tingling and weakness in the lower back, buttocks, legs and feet
Ankylosing spondylitis (swelling of the joints in the spine) – pain and stiffness that’s usually worse in the morning and improves with movement
Spondylolisthesis (a bone in the spine slipping out of position) – lower back pain, stiffness, numbness and a tingling sensation
What are rare, serious medical conditions that can cause back pain?
Broken bone in the spine
Infection
Cauda equina syndrome (where the nerves in the lower back become severely compressed)
Some types of cancer, such as multiple myeloma (a type of bone marrow cancer)
What are some treatments patients can do themselves to help their back pain?
Staying active
Back exercises and stretches
Regular exercise to keep back strong - walking, swimming, yoga, pilates
Painkillers NSAIDs e.g. ibuprofen, codeine (paracetamol on its own is not recommended, but can be used alongside stronger painkillers)
Muscle relaxants e.g. diazepam prescribed by the GP to reduce muscle spasms
Hot and cold packs
Relax and stay positive - stress busters and breathing exercises
What are specialist treatments provided by healthcare professionals?
Exercise classes - NHS group exercise programme
Manual therapy - physiotherapisys, chiropractors, osteopaths
Psychological support - CBT to manage back pain
Surgery - recommended only when there is a specific medical reason e.g. sciatica or slipped disc
What surgeries can be recommended?
Nerve Treatment = radiofrequency denervation: awake with local anaesthesia, insert needles into the nerves that supply the affected joints, send radio waves through the needles to heat the nerves, which stop them sending pain signals
Recommended to people who have had back pain for a long time, pain is moderate to severe, and pain is thought to originate from the joints in your spine
Spinal fusion surgery = fuse 2 vertebrae together to strengthen them - reduces nerve related pain as it stops damaged vertebrae squeezing the nerves passing through
Recommended to those with significant damage to vertebrae
What are some side effects to a spinal fusion surgery?
Permanent damage to some nerves in the back, may lead to partial paralysis of legs, bowel or urinary incontinence
1 in 200 experience these complications
What are some treatments not recommended by NICE due to lack of evidence?
Belts, corsets, foot orthotics and shoes with “rocker” soles
Traction – the use of weights, ropes and pulleys to apply force to tissues around the spine
Acupuncture – a treatment where fine needles are inserted at different points in the body
Therapeutic ultrasound – where sound waves are directed at your back to accelerate healing and encourage tissue repair
Transcutaneous electrical nerve stimulation (TENS) – where a machine is used to deliver small electrical pulses to your back through electrodes (small sticky patches) attached to your skin
Percutaneous electrical nerve stimulation (PENS) – where electrical pulses are passed along needles inserted near the nerves in the back
Interferential therapy (IFT) – where a device is used to pass an electrical current through your back to try to accelerate healing
Painkilling spinal injections (although these can help if you have sciatica)
What are the 3 important arrangements of the CNS relevant to touch and pain sensation?
- Somatotopic arrangement in the somatosensory cortex
- Contralateral arrangement of brain - nerves cross over at the medulla oblangata (decussation)
- Effective neuroscience = stimulation of a particular region of the brain by the right type of signal = physiological output
e. g. amgydala = fear, cingulate cortex = aversion, insula = vasconstriction + sweating, reticular formation in brainstem = arousal
What is the science behind touch?
Touch = aims to stimulate right part of the somatosensory cortex
Touch detected by touch and pressure receptors (low threshold nerve endings) = must excite the correct neuron travelling to the correct region of the somatosensory cortex
Pathway of neurons for touch:
low threshold receptors –> 1st sensory neuron –> medulla oblangata –> synapse to 2nd neuron which then crosses over (decussation) –> thalamus –> synapse to 3rd neuron –> somatosensory cortex
This is called the dorsal column medial column limbiscus system
What is the science behind pain?
What are the 2 pathways and different types of nerve fibres?
Pain = nocioceptive receptors found on high threshold neurons
Higher stimulus needed to evoke response from high threshold neurons - leads to conformational change of the receptor = transduction (changing of stimulus to action potential)
3 types of stimulus: mechanical (pressure), thermal (heat), chemical (chemokines)
2 pathways:
- Sharp (a-delta fibres): 1st sesnory neuron via neospinothalamic tract –> dorsal horn of spinal cord –> synapse to 2nd neuron which then crosses over (decussation) –> thalamus –> synapse to 3rd neuron –> somatosensry –> and S2 region for physiological response
- Slow (c fibres):1st sesnory neuron via neospinothalamic tract –> dorsal horn of spinal cord –> synapse to 2nd neuron which then crosses over (decussation) –> reticular formation (in brainstem) –> thalamus –> synapse to 3rd neuron –> somatosensory –> cingulate cortex for sense of aversion –> amygdala for sense of fear
Pain takes the spinothalamic tract pathway
Why does slow dull pain keep you awake at night?
Slow pain pathway goes via reticular formation in the brainstem = responsible for arousal
Also cingulate cortex (aversion) + amygdala (fear)
Why does the sharp and slow pathway have different nerve fibres?
Difference in axon thickness and myelation = different speed limits
What does the reflex arc pathway follow?
Reflex arc = sensory neurone synapses at dorsal column, and motor neuron comes back from dorsal column to the appropriate effectors
Information does not travel to the brain during the reflex action, only the spinal cord
Which of the following options best represents the journey of an action potential due to a pin prick in the right hip?
Mechanoreceptor –> dorsal horn –> thalamus –> left somatosensory cortex
Imagine if the region shown in red is where Paul feels pain (lower central back), which of the options in the poll may be possible causes of his back pain?
Vertebra Spinal Cord Nerve Roots Lumbar muscles Aorta Kidneys Pancreas
Likely to be:
Vertebra
Spinal Cord
Nerve Roots
Lumbar muscles
Aorta (maybe abdominal aorta)
Kidneys
Pancreas
Due to concept of referred pain, even though organs and abdominal aorta are found more central in an axial view
What is the science behind referred pain?
Both, the viscera neurons and skin neurons enter the spinal cord at the same point so the neurons can get mixed
The doctor has ruled out visceral organs of Paul’s pain.
Which of the 3 broad categories of back pain is Paul likely to have?
Mechanical Back pain
Radiculopathy
Cauda Equina Syndrome (CES)
Where is Paul’s pain arising from?
Vertebral body - (Zone A)
Spinal cord - (Zone B)
Spinal nerve = posterior ramus + anterior ramus converge - (Zone C)
Mechanical = catch-all term, broad back pain issue, Zone A, B and C, could be vertebrae, ligaments, muscles etc.
Radiculopathy = Zone C = unilateral symptoms as it is a block in the spinal nerve
Cauda Equina Syndrome (CES) = Zone B or Zone C = multiple spinal roots affected = shooting pain
Paul = CES
Where is the Cauda Equina?
So what is Cauda Equina Syndrome (CES)?
Group of nerves stemming from the distal end of the spinal cord, typically below L1, which is where the spinal cord terminates
Something that impinges at the L1 or L2 region (or below)
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Explain the pathophysiology of the most common cause of cauda equina.
Why can CES present with unilateral or bilateral symptoms techincally?
Slipped disc -
Disc is made of harder anulus fibrosus on the outer edge, and jelly like substance in the middle called nucleus pulposus
The jelly can escape the anulus fibrosus border, and spill into the region with the spinal cord, compressing the spinal roots OR spinal cord
Depending on where the jelly spills into:
Spinal root impinged = unilateral symptoms
Spinal cord impinged = bilateral symptoms
Results in shooting pain
What is the development of the spinal cord in the embryo?
Spinal cord grows significantly slower than the vertebrae
8 weeks = spinal cord and vertebra same length
24 weeks = spinal cord only reaches S1
Neonate = spinal cord only reaches L2 to L3
Adult = spinal cord only reaches L1 / L2 (spinal roots have a long cord to get where they need to)
What red flag symptoms are required to suspect CES?
Nerves supplying the bladder and perineum are affected:
Reduced perianal sensation - around anus and genitals
Sexual dysfunction
Painless urinary retention
Change in bladder function
Bilateral symptoms - bilateral leg weakness / numbness
What are the most common causes of CES?
Herniated disc = bulge of jelly spilling out impinges on nerve
Other causes = tumours, abnormal blood vessels
What is done clinically when a patient presents with CES?
Urgent scan and neuro consult
Requires surgery with 24-48hrs of onset of symptoms
Why does the impingement of the nerves in the CE cause difficulty initiating micturition (action of urinating)?
Use your knowledge of the ANS.
Nerves below L4/L5 are affected
So the only the PNS innervation of the pelvic nerves are affected:
The sympathetic NS supplying the bladder = L1 to L3 = keeping the muscles contracted to stop you peeing
Promotes detrusor relaxation and internal sphincter contraction
The parasympathetic NS which initiates micturition is affected = PNS makes you pee
Promotes detrusor contraction and internal sphincter relaxation
What is overflow incontinence and why does it occur?
Eventually bladder is so full, pressure of urine in bladder pushes open sphincter
Patient pees themselves
What are the red flags for CES that the doctor was seeking in Paul?
Have you had issues with your sexual functioning?
Are you passing urine normally? (urinary retention)
Have you had saddle numbness / parasthesia?
What are the red flag symptoms in CES?
Bilateral sciatica
Severe or progressive bilateral neurological deficit of the legs, such as a major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to be irreversible
Urinary retention with overflow urinary inconstinence
Loss of sensation of rectal fullness, if untreated this may lead irreversible
Faecal inconstinence
Perianal, perineal or genital sensory loss (saddle anaesthesia or parasthesia)
Laxity of the anal sphincter
Consider an assessment of anal tone but note that this does not need to be performed in primary care
Which of the red flags did Paul confirm he had?
Urinary retention
New bilateral leg symptoms - including pins and needles
What questions would you ask Paul to identify the red flag symptoms?
Any changes in passing urine?
Difficulty passing urine?
Have you had any numbness / pins and needles? Can you describe where?
Does your skin feel normal when you sit down?
When you wipe yourself in the toilet, do you feel a change in sensation?
Have you noticed a change in sexual function?
What are the early warning signs for Cauda Equina Syndrome?
Loss of feeling / pins and needles between inner thighs or genitals
Numbness in or around your back passage or buttocks
Altered feeling when using toilet paper to wipe yourself
Increasing difficulty when you try to urinate
Increasing difficulty when you true to stop or control your flow of urine
Loss of sensation when you pass urine
Leaking urine or recent need to use pads
Not know when you bladder is either empty or full
Inability to stop a bowel movement or leaking
Loss of sensation when you pass bowel motion
Change in ability to achieve an erection or ejaculate
Loss of sensation in the genitals during sexual intercourse
Sexual dysfunction mainly noticed in male patients - important to explain why you are asking these questions
Can the history and symptoms confirm CES?
No, must get MRI scan of vertebrae
Need for MRI determined by presence of red flag symptoms
Why is it that Paul has had back pain for many years, but now he has CES?
Could have had unrelated mechanical back pain for years, now presenting with new pain due to CES
Could have had radiculopathy for years, and now new pain due to CES
Differentiate between normal pain and new pain
Why is the timeline important?
Order of symptoms and when they started = idea of how progressed the CES is
As some symptoms may be irreversible if left untreated for long enough
How does age affect the presence / reason of CES
CES due to disc herniation = working class = 30-40 y/o
60+ = more likely to be tumour etc.
What should the clinical record include?
Relevant clinical findings - all red flag symptoms asked
The decisions made and actions agreed, and who is making the decisions and agreeing the actions
Information given to patients - of red flag symptoms and where to go
Any drugs prescribed or other investigations or treatments
Who is making the record and when
What does it feel like to have CES from a patient’s perspective?
Intermittent back pain from lumbosacral area - jabbing / stabbing pain
For 2 years
No leg symptoms
CAT scan came back normal
Then began getting numbness on soles of feet - when sitting / standing
Excruciating pain
Had neurosurgery - couldn’t walk up steps for 6 months
What are the 3 types of CES presentation?
- Chronic back pain
- Sudden onset
- Gradual onset
Why is documentation of CES important?
Affects working age people Can cause permanent incontinence Permanent leg weakness Massive medicolegal issue Payouts in the millions - devastating affects to NHS finances
Write positive and negative findings
What must a claimant show for a CES claim to be successful? i.e. delayed CES diagnosis causing further issues in patient
- ‘Breach of duty’ = Show the care provided by a doctor fell below reasonable standard
- ‘Causation’ = show the breach has caused loss or damage
What makes up the bulk of a CSE claim?
Damage resulted from breach of duty
Consequent care costs
Loss of earnings if they are no longer able to continue working
How many claims were notified to the MDU between Jan 2005 and Aug 2016?
150
70% successfully defended
£350,000 were spent on legal costs
£8 million in compensation paid out
Damages payments ranged from £2,250 to £670,000
Where do surgeons make the incision in CES surgery?
Right over the area where the disc has herniated
What must surgeons cut through to reach the CE?
Small area of lamina that is removed to get into canal
Ligamentum flavum (separates back of the canal to the nerves) must be removed to expose spinal canal
Spinal nerves are retracted
What is done after surgery?
Probe underneath the nerve sac to make sure it is free
