Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Junior Doctor working in the Emergency Department. Your next patient is a 45-year-old gentleman, Adam Apples, who presents back pain after being hit by a slow-moving car yesterday. Please take a history and perform an appropriate examination.
Patient History:
Adam Apples, a 45-year-old gentleman, banker
You came in today following a small car collision towards your back while walking across the road last night. You brushed this off – thinking it was no big idea. However, you started noticing lower back pain with weakness in your lower limbs.
Back pain is located centrally in the lower back – can sometimes radiate down both legs. You describe the pain as sharp, rating it 10/10. You tried many things to ease the pain without success e.g. paracetamol and ibuprofen. Back pain can be triggered by simple back movement but not worsened by coughing or straining. You have numbness and tingling sensation running down both of your legs.
Also, while wiping yourself afterwards in the toilet, you couldn’t feel the sensation around your bottom as well as your genitals– it was very strange, and at that point, you knew you needed to go and seek medical attention. You developed incontinence for passing urine and faeces. You no longer have the urge to go the toilet, and they can come out involuntarily, which is very concerning for you—no other previous back injuries.
Idea, Concern, Expectation:
You have no idea what is going on, but you think it is related to yesterday's injury. You are very concerned and don’t want to be paralysed – you are still very young! You would like to find out what is going on. You are very scared if you need any surgery for this.
Past Medical History:
Hypertension, obesity
Drug History:
Ramipril, Atorvastatin
NKDA
Family History:
Ankylosing Spondylitis
Social History:
Smoke 10 cigarettes/day for over 20 years
Drink around 2-3 pints of beer every weekend
Work as a banker
Live with a wife and two kids in a semi-detached house
Examination Findings:
Both lower limbs power 4/5 with reduced sensations, tone, and reflexes.
Lower back spinal tenderness at L3/4 region.
PR Examination: Reduced anal tone and sensation.
No upper motor neurone signs
Differentials:
Caudal Equina Syndrome caused by trauma
Prolapsed lumbar disc
Conus medullaris syndrome
Mechanical back pain
Peripheral neuropathy
Spinal tumour
Investigations:
Basic observations
Routine bloods for baseline and pre-assessment e.g. FBC, U&Es, LFT, Bone Profile, CRP
Consider blood culture if suspected infection.
Emergency MRI to confirm and exclude cauda equina syndrome
Consider CT myelography/spine
Consider XR spine
Consider Urodynamic studies -to monitor bladder function
Management (Cauda Equina Syndrome):