Thanks for reading the 46th edition of my newsletter. This newsletter tracks my research as I write a book about sciatica, and another one about cauda equina syndrome. EDIT - an improved version of this post is here. If I'm honest, when I first started practicing it took me a long time to get a good idea in my head of what CES actually is.
Hi Tom I actually am one of those rare people that had to have emergency decompression surgery for ces. 12 weeks before this I had a stroke, pretty unlucky time just as the covid pandemic started, unfortunately when I went to a&e I was kept in 12 hours then discharged under sciatica, although I told them all the red flags and even asked if it could be ces but they didn’t listen, two days later after given an mri I was sent straight to surgery, I think there is so much more that needs to be taught to drs and nurses, students to be able to be more aware of ces red flags, as in my own personal experience very few drs, surgeons, nurses, still have very little knowledge of it and the aftermath destruction of lifetime disabling issues and pains were left with and still not believed or have a aftercare pathway. However I’m more than happy to help in any questions to better help drs nurses students gain more knowledge of ces.
So clear and well written Tom. Graeme’s comments on common things is important too I feel . This is the way inservice education should be ! Do you refer to Jon stones scan negative research? The biomedical information is obviously important but so too is the amount of complex stress patterns coupled with depression etc . In a back clinic I worked in so many cases were a complex mix of things seldom needing neurosurgery intervention. Ian
Hi Tom. a great outline of what CES is for all developing clinicians and some already developed ! Well done.
One comment drawing on near to 40 years of practice and some of the learning I have had. I have seen a conflict in clinical reasoning and risk management in this condition from others which relates to the magnitude of settlements of medico legal cases and this can lead to "just send everything in to avoid risk" which overloads the system and ultimately may influence adverse outcomes and waiting times in ED for other people. Hence and as you have indicated at the end this is not common - its rare but it happens :
- "common things happen commonly " - so the presentation of an aging ( you can define that!) patient with back pain radiating to the leg ( and facet pain does too) and urinary symptoms of urgency, leakage, etc is not uncommon ... the urinary symptoms have been developing for urological not neural reasons for months and years and back pain is well just very very common. The leg pain may be leg pain and not related to the back pain other than part of lots of pain everywhere ini some patients and how common is that !
Medical practice is some science some "art". Key thing is to be on the lookout, take a careful history and talk to others if you aren't sure/ absolutely err on the side of caution but if you are doing this several times a year then you are over sensitive.
Document your reasoning ( which of course needs to be valid when examined after the event)) and remember you don't have to get it right all the time , just most of the time but where you reached a different conclusion for that patient than was proved at some future date - your reasoning at that point in time ( not in retrospect as is common from the "knew it after the event brigade") must be valid
Clear explanation like this from Tom should give more confidence but ask seniors if you are not sure on your reasoning....
Hi Tom I actually am one of those rare people that had to have emergency decompression surgery for ces. 12 weeks before this I had a stroke, pretty unlucky time just as the covid pandemic started, unfortunately when I went to a&e I was kept in 12 hours then discharged under sciatica, although I told them all the red flags and even asked if it could be ces but they didn’t listen, two days later after given an mri I was sent straight to surgery, I think there is so much more that needs to be taught to drs and nurses, students to be able to be more aware of ces red flags, as in my own personal experience very few drs, surgeons, nurses, still have very little knowledge of it and the aftermath destruction of lifetime disabling issues and pains were left with and still not believed or have a aftercare pathway. However I’m more than happy to help in any questions to better help drs nurses students gain more knowledge of ces.
Kind regards
Tantra
So clear and well written Tom. Graeme’s comments on common things is important too I feel . This is the way inservice education should be ! Do you refer to Jon stones scan negative research? The biomedical information is obviously important but so too is the amount of complex stress patterns coupled with depression etc . In a back clinic I worked in so many cases were a complex mix of things seldom needing neurosurgery intervention. Ian
Hi Tom. a great outline of what CES is for all developing clinicians and some already developed ! Well done.
One comment drawing on near to 40 years of practice and some of the learning I have had. I have seen a conflict in clinical reasoning and risk management in this condition from others which relates to the magnitude of settlements of medico legal cases and this can lead to "just send everything in to avoid risk" which overloads the system and ultimately may influence adverse outcomes and waiting times in ED for other people. Hence and as you have indicated at the end this is not common - its rare but it happens :
- "common things happen commonly " - so the presentation of an aging ( you can define that!) patient with back pain radiating to the leg ( and facet pain does too) and urinary symptoms of urgency, leakage, etc is not uncommon ... the urinary symptoms have been developing for urological not neural reasons for months and years and back pain is well just very very common. The leg pain may be leg pain and not related to the back pain other than part of lots of pain everywhere ini some patients and how common is that !
Medical practice is some science some "art". Key thing is to be on the lookout, take a careful history and talk to others if you aren't sure/ absolutely err on the side of caution but if you are doing this several times a year then you are over sensitive.
Document your reasoning ( which of course needs to be valid when examined after the event)) and remember you don't have to get it right all the time , just most of the time but where you reached a different conclusion for that patient than was proved at some future date - your reasoning at that point in time ( not in retrospect as is common from the "knew it after the event brigade") must be valid
Clear explanation like this from Tom should give more confidence but ask seniors if you are not sure on your reasoning....