Paul Bennet

Question 1

What does Paul’s patient profile tell us?

Answer 1

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

Question 2

What does Paul talk about in the case video?

Answer 2

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

Question 3

How can back pain be relieved?

Answer 3

1. Stay as active as possible, try continue with daily activities (resting for long periods likely to make pain worse)
2. Exercises and stretches specifically for back pain, and yoga, swimming, walking etc.
3. NSAIDs = Anti-inflammatory painkillers e.g. ibuprofen
4. Hot or cold compression packs for short term relief

Question 4

When should back pain resolve?

When should you seek help and from who?

Answer 4

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

Question 5

What are the possible treatments for back pain from a specialist?

Answer 5

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

Question 6

What are some causes of back pain?

Answer 6

Often non-specific
Injury - sprain / strain
Slipped (prolapsed) disc - presses on nerve
Sciatica - irritation of the nerve running from pelvis to feet

Question 7

How can back pain be prevented?

Answer 7

Regular back stretches and exercise
Stay active 
Avoid sitting for long periods
Take care when lifting 
Improve posture
Good mattress support
Lose weight

Question 8

When is it important to get immediate advice about back pain?

Answer 8

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

Question 9

What is non-specific back pain?

What are some symptoms and causes of non-specific back pain?

Answer 9

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

Question 10

x

Answer 10

x

Question 11

x

Answer 11

x

Question 12

What are different medical conditions that can cause back pain and how do they present?

Answer 12

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

Question 13

What are rare, serious medical conditions that can cause back pain?

Answer 13

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)

Question 14

What are some treatments patients can do themselves to help their back pain?

Answer 14

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

Question 15

What are specialist treatments provided by healthcare professionals?

Answer 15

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

Question 16

What surgeries can be recommended?

Answer 16

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

Question 17

What are some side effects to a spinal fusion surgery?

Answer 17

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

Question 18

What are some treatments not recommended by NICE due to lack of evidence?

Answer 18

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)

Question 19

What are the 3 important arrangements of the CNS relevant to touch and pain sensation?

Answer 19

1. Somatotopic arrangement in the somatosensory cortex
2. Contralateral arrangement of brain - nerves cross over at the medulla oblangata (decussation)
3. 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

Question 20

What is the science behind touch?

Answer 20

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

Question 21

What is the science behind pain?

What are the 2 pathways and different types of nerve fibres?

Answer 21

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:

1. 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
2. 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

Question 22

Why does slow dull pain keep you awake at night?

Answer 22

Slow pain pathway goes via reticular formation in the brainstem = responsible for arousal
Also cingulate cortex (aversion) + amygdala (fear)

Question 23

Why does the sharp and slow pathway have different nerve fibres?

Answer 23

Difference in axon thickness and myelation = different speed limits

Question 24

What does the reflex arc pathway follow?

Answer 24

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

Question 25

Which of the following options best represents the journey of an action potential due to a pin prick in the right hip?

Answer 25

Mechanoreceptor --> dorsal horn --> thalamus --> left somatosensory cortex

Question 26

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 ```

Answer 26

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

Question 27

What is the science behind referred pain?

Answer 27

Both, the viscera neurons and skin neurons enter the spinal cord at the same point so the neurons can get mixed

Question 28

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)

Answer 28

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

Question 29

Where is the Cauda Equina? So what is Cauda Equina Syndrome (CES)?

Answer 29

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)

Question 30

x

Answer 30

x

Question 31

Explain the pathophysiology of the most common cause of cauda equina. Why can CES present with unilateral or bilateral symptoms techincally?

Answer 31

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

Question 32

What is the development of the spinal cord in the embryo?

Answer 32

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)

Question 33

What red flag symptoms are required to suspect CES?

Answer 33

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

Question 34

What are the most common causes of CES?

Answer 34

Herniated disc = bulge of jelly spilling out impinges on nerve Other causes = tumours, abnormal blood vessels

Question 35

What is done clinically when a patient presents with CES?

Answer 35

Urgent scan and neuro consult | Requires surgery with 24-48hrs of onset of symptoms

Question 36

Why does the impingement of the nerves in the CE cause difficulty initiating micturition (action of urinating)? Use your knowledge of the ANS.

Answer 36

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

Question 37

What is overflow incontinence and why does it occur?

Answer 37

Eventually bladder is so full, pressure of urine in bladder pushes open sphincter Patient pees themselves

Question 38

What are the red flags for CES that the doctor was seeking in Paul?

Answer 38

Have you had issues with your sexual functioning? Are you passing urine normally? (urinary retention) Have you had saddle numbness / parasthesia?

Question 39

What are the red flag symptoms in CES?

Answer 39

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

Question 40

Which of the red flags did Paul confirm he had?

Answer 40

Urinary retention | New bilateral leg symptoms - including pins and needles

Question 41

What questions would you ask Paul to identify the red flag symptoms?

Answer 41

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?

Question 42

What are the early warning signs for Cauda Equina Syndrome?

Answer 42

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

Question 43

Can the history and symptoms confirm CES?

Answer 43

No, must get MRI scan of vertebrae Need for MRI determined by presence of red flag symptoms

Question 44

Why is it that Paul has had back pain for many years, but now he has CES?

Answer 44

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

Question 45

Why is the timeline important?

Answer 45

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

Question 46

How does age affect the presence / reason of CES

Answer 46

CES due to disc herniation = working class = 30-40 y/o | 60+ = more likely to be tumour etc.

Question 47

What should the clinical record include?

Answer 47

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

Question 48

What does it feel like to have CES from a patient's perspective?

Answer 48

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

Question 49

What are the 3 types of CES presentation?

Answer 49

1. Chronic back pain 2. Sudden onset 3. Gradual onset

Question 50

Why is documentation of CES important?

Answer 50

``` 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

Question 51

What must a claimant show for a CES claim to be successful? i.e. delayed CES diagnosis causing further issues in patient

Answer 51

1. 'Breach of duty' = Show the care provided by a doctor fell below reasonable standard 2. 'Causation' = show the breach has caused loss or damage

Question 52

What makes up the bulk of a CSE claim?

Answer 52

Damage resulted from breach of duty Consequent care costs Loss of earnings if they are no longer able to continue working

Question 53

How many claims were notified to the MDU between Jan 2005 and Aug 2016?

Answer 53

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

Question 54

Where do surgeons make the incision in CES surgery?

Answer 54

Right over the area where the disc has herniated

Question 55

What must surgeons cut through to reach the CE?

Answer 55

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

Question 56

What is done after surgery?

Answer 56

Probe underneath the nerve sac to make sure it is free