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Don’t be blind to red flags

01 September 2009

Mrs T, a 40-year-old school secretary, had previously been diagnosed with hypothyrodism for which she was taking levothyroxine. Her thyroid function tests had been stable for many years. In addition, she had been prescribed citalopram for depression since the loss of her mother two years ago, and omeprazole for gastro-oesophageal reflux.

She had been suffering from back pain for a number of months, which had become progressively worse over a couple of weeks. There was no history of trauma although she thought her worsening pain may have been related to moving her office furniture around. She subsequently consulted her GP, Dr D, who diagnosed muscular spasm and prescribed painkillers.

Mrs T promptly reattended the surgery when her back pain became significantly worse following a severe coughing fit. Dr D made a revised diagnosis of sciatica and changed the analgesia accordingly. His notes, however, were limited to “looks well; walked into surgery”. Mrs T later alleged that Dr D did not perform a physical examination.

Over the next three days Mrs T deteriorated, with worsening discomfort in her back to the extent that she was unable to go to work and needed her husband to help her shower and dress. In addition to the severe back pain, she began to experience urinary symptoms and altered sensation. In desperation, Mrs T rang the surgery twice, over a three-day period, to say that she was having difficulty passing water

and that her buttocks “felt funny”. She discussed her situation with Dr D, although documentation on these conversations was very limited and did not reflect the development of these red-flag symptoms, the full severity of her symptoms or the appropriate use of safety-netting. Mrs T alleged that Dr D advised her to increase the amount of fluid she was taking without offering to assess her in a face-to-face consultation.

Her symptoms deteriorated even further and five days after the severe pain started Mrs T attended the local out-of-hours GP service. She was thoroughly examined by the emergency GP and was noticed to be in urinary retention, her bladder being palpable to the level of the umbilicus. The out-of-hours GP also found that Mrs T had numbness of the perineum.

As a result, a diagnosis of cauda equina syndrome was made and she was referred urgently to the orthopaedic registrar on call. An MRI scan confirmed a prolapsed inter-vertebral disc at L5/S1. Given the acute neurological presentation, she underwent an emergency laminectomy and excision of the prolapsed L5/S1 disc.

Following the surgery, Mrs T continued to experience a lack of feeling in her perineal region. She was deeply distressed that the sensory loss caused major sexual difficulties and this had a profound impact on the relationship with her husband. Her depression deepened and she felt inadequate as a wife and a woman.

In addition to increasing the dose of citalopram, she required intense psychological support. Mrs T was forced to self-catheterise several times a day, which she found humiliating, and suffered a number of urinary tract infections.

Mrs T made a claim against Dr D and experts on the matter agreed that the care received was substandard, that Dr D had failed to examine or take heed of worsening and serious symptoms, and had cauda equina been diagnosed sooner the final outcome would have been much more positive. The claim was settled for a substantial amount.

Learning points

  • Chronic back pain is common – cauda equina is not. Therefore it is very important to take a good history to identify the “red flags” symptoms, eg, numb buttock, urinary symptoms. 
  • Certain symptoms almost always need physical examination to avoid missing clues. 
  • It is important to remember the limitations of telephone consultations. It is not possible to make an accurate diagnosis in all circumstances or to assess accurately signs such as perineal numbness over the phone. It is important to get enough information to exercise reasonable judgment. 
  • Documenting everything, including telephone conversations, is always the key to good practice, and the foundation of your defence.
  • Please see the feature on cauda equina syndrome from the September 2009 edition of Casebook.