Over to you

We welcome all contributions to Over to you. We reserve the right to edit submissions. Please address correspondence to: Casebook, MPS, Granary Wharf House, Leeds LS11 5PY, UK. Alternatively, email your comments to casebook@mps.org.uk.

Cauda equina syndrome

Gardner and Morley’s excellent article on cauda equina syndrome (Casebook 17(3)) is most informative and timely. CES will, as they say, “continue to occupy a prominent position in the medicolegal field”, so long as it is not in the forefront of every GP’s (and other doctors’) minds when confronted by a patient with back pain and (often) bilateral leg pain (to which patients will readily admit spontaneously).

It is also worth noting that one result of the (relatively) new, shortened training period in orthopaedics, and in neurosurgery, coupled with the recent introduction of the 48-hour week, is that many of this new generation of consultants – who are likely to be on the general on-call rota in a typical district general hospital – will never have done, or even seen, an emergency decompression for CES.

A very useful overview on the presentation and management of CES is to be found in the British Medical Journal article by Lavy et al.

John Lourie
Consultant orthopaedic surgeon (UK)

  • Reference: Lavy C, James A, Wilson MacDonald J, Fairbank J, Cauda Equina Syndrome, Br Med J 338:881-4 (11 April 2009)

 

A long-lasting earache

I was aghast to see the illustration accompanying the case report, “A long-lasting earache”, and repeated in miniature on page 3, of the September 2009 edition of Casebook. Any trainee audiologist or hearing aid dispenser would be failed instantly if he/she examined a patient’s ear in that way.

With respect to your recent illustration, I doubt if anyone will actually come to any harm because of it. But in a publication devoted to prevention of malpractice and accidents, it was certainly a very unfortunate mistake.

Dr Ross Coles

(Ed’s note: We apologise for any confusion this illustration caused. But it should be noted that the illustrations we use are merely indicative and not intended to be representative of actual events.)

 

Not just another headache

I was interested in your case report, “Not just another headache” (Casebook 17(3)). I am delighted to hear that Dr A was supported and the claim was successfully defended but I think it does send out an unfortunate message.

My understanding (and this is the opinion I have given as an expert witness in the past) is that a sudden onset headache must be assumed to be a subarachnoid haemorrhage until proved otherwise. I am aware that when such headaches are properly investigated by CT scan and, if necessary, lumbar puncture, only one in three turns out to be subarachnoid haemorrhage – but, given the catastrophic consequences of not making the diagnosis at the right time, a risk of one in three is quite enough for me to want to send any sudden onset headache into hospital.

Dr Gavin Young
GP, UK

 

Correction

“Too late for contraception” – Casebook Vol. 17 no. 2, May 2009

MPS would like to correct the fourth learning point that was included at the end of the above case report. The statement – “clinicians must take adequate measures to ensure that a patient is not pregnant prior to fitting an IUCD. this should include fitting the device within a few days of the first day of her period or, if not possible, obtaining a negative pregnancy test within the 48 hours before the device is fitted” – does not fully reflect current NICE guidance which states that: “Provided it is reasonably certain that the woman is not pregnant, an IUD may be inserted:

  • at any time during the menstrual cycle 
  • immediately after 1st or 2nd trimester abortion 
  • from four weeks post-partum, irrespective of the mode of delivery.”