spine for everyone cases

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.

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Case 1 – acute back pain

Background:

54-year-old hairdresser. 

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

Presenting Complaint:

  • 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. 

Neurological findings:

  • 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

PR exam

  • Can discriminate sharp and blunt sensation bilaterally S2 to S5.
  • Anal tone normal
  • Able to voluntarily contract external sphincter. 
  • Hard stool in rectum. 

The patient gets referred to ortho at 3.00 am What would you do/say? (be honest!)

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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.

Is this helpful/relevant or not?

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Morning comes.  She got admitted overnight and she’s seen on the post-take wardround.

She is much more comfortable with the analgesia

What do you think is the most likely thing to happen now, in your experience?

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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.

What is the level of urgency at which things should proceed at this point?

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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

the report mentions something about sponsylosithesis and pars defect

A diagnosis is made from the CT

What do you think the aetiology might be?

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Which of the following investigations is least helpful at this point?

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How would you manage this patient in the short term?

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How would you manage this patient in the long term?

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If this condition were to arise in a 17-yr old volleyball player, 5-week Hx; what would be your initial treatment?

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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

What is the likely diagnosis?

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What is the likely mechanism of injury?

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What initial imaging of the cervical spine should be performed?

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What is the surgical priority?

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When should spinal cord decompression be undertaken?

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What stabilisation procedure should be undertaken?

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After surgery, what is the likelihood of recovery of sufficient neurological function to allow this boy to walk again?

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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

Can you see any concerning abnormality?

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On MRI one might be concerned if the vertebral body shows low signal on T1:

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Always consider giving an injection before proceeding with other treatments.

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She had osteopathy, physio, Pilates and Chiro – no improvement

Steroid injection – gave some mild, temporary relief

She remains unhappy and struggling at work

What is the next step with this lady?

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Webinar

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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