A Pain in the Back

According to the patient, the pain was radiating both up to his neck, and down to his knees. On examination, the GP observed that the patient’s straight leg and lumbar flexion was limited. The GP provided the patient with referrals for an x-ray, CT scans of his lumbar spine and a referral for physiotherapy treatment. He was asked to return with the results of his radiological investigations.

Case history

The patient returned to the GP on the 10th of August 2004. The GP noted when she was reviewing the films, that there was a mild disc bulge at the L3/4 level, and a moderately large right-sided disc prolapse at the L4/5 level. The GP recommended that the patient’s back pain be managed conservatively, and asked that he return if his symptoms did not improve with physiotherapy. Although the patient was subsequently seen on 2 occasions in October 2004, he made no mention to the GP of any back pain. The patient did not return to the GP’s practice after October 2004.

On the 3rd of November 2005, the patient experienced the onset of back pain while he was at work. He sought treatment from an after hours clinic and was given anti-inflammatory medication for an acute flare-up of lower back pain.

A week later, on the 10th of November 2005, the patient presented to the Emergency Department of his local hospital. When examined by theCMO, the patient was complaining of severe back pain, numbness in his bottom, thigh, back, and right leg. The CMO noted that the patient appeared to have difficulty walking.

The patient was subsequently reviewed by the Neurosurgical Registrar. After undergoing a CT scan, the patient was discharged by the Registrar with a diagnosis of right sided disc bulge at the L4/5 level. However, the patient was brought to hospital by ambulance the following day, with severe abdominal pain, urinary frequency and dysuria. An IDC was inserted, and almost two litres of urine was drained. An MRI scan was urgently performed. This was reported as showing an L4/5 disc sequestration, with cauda equina compression. Although the patient underwent urgent laminectomies and discectomies, he was left with bowel and bladder incontinence, and significant weakness of his right leg.

Medico-legal issues

In December 2006, the patient commenced legal proceedings against the hospital. The patient alleged in his Statement of Claim that the hospital was negligent in:-

• Failing to adequately consider the patient’s history of sacral numbness and bilateral leg sensory symptoms on the 10th of November 2005;
• Failing to perform an MRI scan when it was clinically indicated;
• Failing to diagnose an incomplete cauda equina lesion;
• Inappropriately discharging the patient home.

The solicitors instructed on behalf of the hospital wrote to the GP in March 2007. They stated that the hospital would be seeking a contribution from the GP, with respect to any damages awarded to the patient. The GP sought advice from MDA National.

An expert neurosurgeon instructed on behalf of the patient was extremely critical of the decision to discharge the patient home on the 10th of November 2005. The Neurosurgeon expressed the view that if a diagnosis of incomplete cauda equina syndrome had been made on the 10th of November 2005, and the lesion had been surgically decompressed, the patient would most likely have maintained normal bowel and bladder function.

The hospital served a report of a General Practitioner, which was extremely critical of the GP’s care. According to the hospital’s expert, the sudden onset of unexplained back pain in a fit and well 29 year old male was a red flag indicator of a potentially serious condition, thereby warranting further investigation. The failure by the GP to refer the patient to a Neurosurgeon, or to arrange for an MRI scan to be performed in the expert’s opinion constituted an unacceptable departure from usual practice.

However, the GP expert instructed by MDA National on behalf of the GP was most supportive of the patient’s management. The expert was of the view that appropriate investigations had been performed by the GP, and that a conservative approach to the management of lower back pain (which resolved without intervention in late 2004) was appropriate.

The hospital subsequently withdrew the claim for contribution against the GP.

Discussion

The importance of accurately documenting follow-up instructions given to a patient is highlighted by this case. As the GP had written extremely comprehensive notes regarding her discussions with the patient, she was able to prove that she had discussed the patient’s CT scan results with him, her reasons for initially recommending a conservative approach to treatment, and the follow-up instructions provided to the patient.

Ideally, the GP would have followed up the patient’s back pain during his subsequent consultations in October 2004. However, the parties agreed that it was unlikely the patient would have failed to mention his back pain to the GP in October 2004 if he had been experiencing significant symptoms at this time.