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)