Intended for healthcare professionals

Rapid response to:

Endgames Spot Diagnosis

A woman with lower back pain

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1117 (Published 16 March 2017) Cite this as: BMJ 2017;356:j1117

Rapid Response:

Not just a woman with lower back pain: she has back pain with radiculopathy, and/or back pain with specific spinal level motor weakness

Dear Editors

I am aware the article is meant to be teaching material for readers but I am concerned that this may further perpetuate myths and misunderstanding, particularly when the authors are in the trauma and orthopaedic training program.

The issues in contention are as follows:

1. The history and findings given in the leading thread are substandard. I believe that it is far more helpful to have a good grasp of the timeline and relationship of onset of symptoms: back pain, radicular pain to the legs, leg muscle weakness. It is important to determine if any of them are pre-existing (eg muscle weakness) and where possible, identify any specific precipitating event, eg a big sneeze or cough etc.

It is frustrating to note that the following description of neurological findings given by the authors is considered good enough for publication: "Neurological examination revealed reduced power in her left leg of 3/5, but was otherwise normal." Some non-spinal colleagues may think this is acceptable but I consider this nebulous statement of clinical finding in medical record appallingly inadequate and in certain cases, indefensible in medico-legal dispute involving any doctor, orthopaedic specialist or not.

Readers should be reminded that even for non-spinal specialists, there is material easily available to assist the uninitiated and untrained clinician to at least provide some rudimentary documentation of neurological finding in presence of spinal deficit; the ASIA score sheet, for example, is easily accessible on the internet (ref 1) and should be available at any emergency department. Fellow colleagues who care to follow up on this reference will find it very easy to use.

Clinicians should also note if they think the specific muscle weakness is due to pain inhibition or true neurological deficit, which leads to another point: there should not be hesitation in providing adequate analgesia (as long as you are not depressing consciousness too much) before clinical examination. Providing just adequate analgesia will not "mask" pain as long as the patient is conscious and cooperative. This will reduce the unhelpful finding of "global weakness" due to difficulty in cooperating because of uncontrolled pain.

2. Unfortunately the use of a single picture of MRI lumbar spine at T2 mid-sagittal perpetuates the myth that vertebral disc pathology is a condition affecting sagittal structures.

It is not. Ref 2 which describes specific terminology also illustrates how disc pathology is a 3-dimensional entity and which is why spine imaging should never be viewed predominantly in sagittal cuts. There are pathologies involving canal recesses and far lateral lesions which are usually best seen on axial views.

3. The following statements may cause confusion in some readers: "Examination findings include radicular pain, sensory loss, weakness, and reduced reflexes. This is caused by impingement of the exiting nerve root of the spinal nerve above. A herniated disc at the level of L4/L5, as in this case, can cause impingement on the L5 nerve root leading to pain and altered sensation in the L5 dermatome (lateral aspect of the leg and dorsum of the foot) and weakness in the L5 myotome (reduced dorsiflexion, eversion, and inversion of the ankle and reduce extension of the toes)."

A midline disc prolapse at L4/5 is unlikely to be affecting the "exiting nerve root of the spinal nerve above" ie L4, since the exiting nerve root actually exits through the superior aspect of the spinal foramina which is lateral and partially superior to the level of disc (see http://www.chirogeek.com/Anatomy%20Page/Images/Anatomy%20PG/traver-exit-...). It will however likely affect nerve roots (eg L5) traversing the canal in the midline.

I would like to thank Dr Symonds for bringing my attention to this article with his rapid response. However, I also take issue with this statement written by Dr Symonds:

"The treatment, we are informed, is ‘initial rest and analgesia followed by physiotherapy’ – in other words, doing nothing."

Advising rest, adequate analgesia and mobilisation (with or without therapy) is NOT doing nothing. In fact it is often the hardest thing for the patient to accept, and thus similarly for the doctor to advise/recommend. Non-procedural treatments are nowadays less likely to be acceptable to some patients, bombarded by news of quick fixes, "medical miracles" and "new operations", and they do not accept the need to take time out to rest.

Similarly surgeons who are trained by and large to perform operations, are more comfortable in performing procedures rather than counselling patients, which may take more patience and skill on the part of the doctor!

I am sure Dr Symonds as a GP has spent quite a lot time counselling patients why their cold does not need antibiotics, rather more rest and supportive therapy; I am sure that would not be considered by anyone as spending hours advising people to "do nothing". Afterall, it is far easier to dish out prescription scripts to every punter that walks through the door.

But then* we, as doctors, are not here to do the easy thing, only the right thing, which is not always what the patient asks for.

Mind you, there is still quite a debate on how best to treat disc prolapse (ref 3). However I do agree that stating "Management options include analgesia, physiotherapy, and activity modification" is not adequate. Non-operative management should also include planning for regular clinical reviews and reassessment of clinical deficits found earlier and advising patients of red-flags to look out for (another can of worms here).

How else can you find progressive neurological deficit if you do not see the patients regularly?

* committing a grammatical heresy here

References:

1. http://asia-spinalinjury.org/wp-content/uploads/2016/02/International_St...
2. http://www.thespinejournalonline.com/article/S1529-9430(14)00409-4/pdf
3. https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDi...

Competing interests: No competing interests

14 April 2017
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia