Mr R, a postman in his sixties, experienced pain radiating from his back down his legs. He saw his GP, Dr J, who examined him and noted that straight-leg raising was limited to 45° bilaterally, with normal reflexes. Dr J diagnosed sciatica and prescribed simple analgesia. Dr J noted that Mr R now lived outside his catchment area, so he advised him to register with a new GP.
About a week later Mr R went to see his new GP, Dr Q, as he had been unable to work due to the pain. Dr Q noted that Mr R had previously been told that he had a degenerative intervertebral disc. Dr Q didn’t document any examination of Mr R.
Mr R was seen several times by Dr Q and his partner Dr Y over the next five months. He had the same back pain radiating to his legs. The notes only record symptoms, prescriptions and monitoring of Mr R’s hypertension. No neurological or locomotor examinations were included. Mr R was signed as unfit for work throughout this period, because of his symptoms.
One weekend Mr R experienced severe back pain and became paralysed below the knees, noticing that he couldn’t pass urine. He didn’t seek medical advice for two days. He was finally assessed as having cauda equina syndrome when he asked for a visit from his local out-of-hours GP co-operative.
Mr R was transferred to a specialist unit where an MRI scan revealed congenital lumbar stenosis with a central intervertebral disc prolapse at level L2/3, compromising the cauda equina. Mr R had surgery but was left with a significant neurological deficit.
We sought expert GP advice, which was critical of the clinical approach of Drs Q and Y. Despite giving sick notes naming sciatica as a diagnosis, implying a neurological problem, neither doctor could show that they had carried out any form of neurological assessment.
The records were ‘unreasonably brief and lack any form of useful clinical detail.’ Neurosurgical opinion concurred noting, ‘If the patient did have bilateral leg symptoms, it is not acceptable not to have written more details in his history, namely the presence of numbness, weakness or sphincter disturbance and also a note to indicate whether he had any neurological deficit or not.’
Neurosurgical advice on causation was that earlier referral to a specialist would have resulted in the performance of a decompressed laminectomy before the onset of the neurological catastrophe, leaving Mr R with little or no long-term disability. Mr R was felt to have contributed somewhat to his own problems by waiting so long to seek medical attention after becoming paralysed.
This was taken into account in the settlement that Mr R received, which was still in excess of £500,000.
When patients complain of back pain radiating down the leg – particularly if it is bilateral – regular and proper examination including a neurological assessment, fully documented in the notes, is advised.
The article on cauda equina syndrome in Casebook UK No 20, gives useful advice on assessing and diagnosing lower back pain, with a view to preventing the onset of irreversible cauda equina syndrome. The box opposite, taken from the article, lists ‘red flags’ which should cause concern in a patient complaining of low-back pain or sciatica.
Red flags for patients with sciatica/low back pain
- Severe low back pain with bilateral or unilateral sciatica
- Bladder/bowel dysfunction
- Anaesthesia/parasthesia in perineal region, scrotum or buttocks
- Significant lower-limb weakness
- Gait disturbances
- Sexual dysfunction