Cauda Equina Syndrome - Back Pain - Clinical History Taking - Dr Gill
Cauda Equina syndrome is one of the most significant spinal emergencies. Whilst here we're not dealing with a compression to the cord, we're dealing with a compression of the nerves after the termination of the cord.
It's very, very important to appreciate the red flags with regard to coquina syndrome, particularly bilateral pain, leg weakness, bladder problems, bowel problems, and numbness
In this video, we will go through the clinical history taking for Cauda equina syndrome (CES) is a serious spinal emergency caused by compression of the nerve roots in the cauda equina below the termination of the spinal cord. Recognising the symptoms and red flags of cauda equina syndrome is essential for medical students, doctors and other healthcare professionals assessing a patient with acute or severe back pain.
In this video, Dr Gill demonstrates a clinical history-taking OSCE with a patient presenting with symptoms suggestive of cauda equina syndrome. The video is designed to help medical students practise their history-taking skills and help doctors and clinicians revise the key clinical features and red flags of cauda equina syndrome.
Cauda equina syndrome: important red flags When taking a history from a patient with back pain, it is important to ask specifically about symptoms that may indicate cauda equina syndrome, including: Bilateral leg pain or sciatica Leg weakness or difficulty walking Numbness or altered sensation, particularly in the saddle/perineal area Bladder dysfunction, including difficulty passing urine, urinary retention or loss of bladder control Bowel dysfunction, including loss of bowel control Saddle anaesthesia Changes in sexual function These symptoms require urgent clinical assessment, as cauda equina syndrome can result in permanent neurological disability if significant nerve compression is not treated promptly. History taking for cauda equina syndrome This clinical history-taking video is particularly useful for: Medical students preparing for OSCEs and clinical examinations Students practising a back pain history Doctors revising cauda equina syndrome Healthcare professionals revising neurological red flags Anyone learning how to assess a patient with suspected cauda equina syndrome The video focuses on the clinical history rather than providing a comprehensive discussion of diagnosis or management. In real clinical practice, suspected cauda equina syndrome requires urgent assessment according to local clinical pathways. Key topics: cauda equina syndrome, CES, back pain, clinical history taking, history of presenting complaint, neurological symptoms, bilateral sciatica, leg weakness, bladder symptoms, bowel symptoms, saddle anaesthesia, urinary retention, spinal emergency, red flags for back pain, OSCE history taking, medical student revision.
Yanni Nazareno, a 51-year-old finance manager, presents with worsening chronic back pain that has progressed from one-sided sciatic pain to bilateral shooting pain (rated 7/10). The patient reports new, concerning symptoms including leg weakness, saddle anesthesia, and urinary/bowel dysfunction, prompting an urgent clinical examination.
Can I check your name and date of birth, please?
Yes, hello. My name is Yanni Nazareno.
My date of birth is 14th December 1972.
OK, thank you. How can I help today?
Well, I've been getting a lot of pain in my back.
OK.
Yeah, and I thought, you know...
I've had this sort of back pain for a while,
but I thought I'd just come and see a doctor.
OK, tell me more.
So, I've been having sort of sciatic pain in my back,
and it was initially, like, going down one leg,
but over the last few days, I feel like...
I think it's gotten worse,
and it's going down the other leg as well.
Oh, dear.
So, you say sciatic pain.
That word can mean different things to different people.
Can you tell me what the pain feels like?
Well, to me, it's like a shooting pain almost,
like from my back going down my buttocks
and then all the way down to my leg.
That's what I define as sciatic pain.
And you said going down to your leg. Does it go below the knee?
Yes, it does go below the knee.
OK, on both legs?
Yes.
OK, so we've got back pain.
It was one-sided, now it's both sides.
It's a shooting pain.
If you were to rate that pain out of ten,
with one being next to nothing and ten the worst pain you can imagine,
where would you put it?
It's about a seven.
OK, so quite a lot.
And how often do you feel the pain?
It's pretty much there constantly.
There are some moments where it gets worse slightly,
but the pain is pretty much quite constant.
OK, and in terms of that getting worse sometimes,
is there anything that makes it better?
To be honest, maybe no, not that I'm aware of at the moment.
I've tried different positions, but it's very uncomfortable,
even sitting down or laying down.
OK, changing the question, does anything make it worse specifically?
I think when I'm walking up the stairs in my house,
it does make it a bit worse.
OK, so it sounds like we've got something very unpleasant going on for you.
Have you taken anything to try and help it?
I've taken some paracetamol, but that's not really touched the pain.
OK, important.
How are you sleeping with it?
It's very uncomfortable, so I'm there trying to roll around in bed,
trying to get a comfortable position.
I eventually fall asleep because I'm so tired,
but sometimes I get woken up by the pain again
because I end up sleeping in a funny position.
OK, so you do get woken by the pain.
Have you found that you can be asleep and the pain wakes you,
or is it that you wake up and you have pain?
It's difficult to tell because obviously I'm quite sleepy when that happens.
But I would probably say that I get woken up with the pain.
I see, OK.
So it sounds like you're really suffering here.
Let's try and get some safety questions and work out if you can see what's underlying this.
Have you noticed any weight loss?
Not that I'm aware of.
OK, that's very good, thank you.
Have you noticed any change in the strength of your legs?
Actually, now that you mention it, I did feel like in the last few days
my legs are starting to feel weak, like they're kind of about to give way,
but I'm still able to walk.
Have they actually given way?
They haven't given way at the moment.
And have you had any falls?
I haven't had any falls.
Have you had any injuries at all to your back?
No.
And historically, have you hurt your back at all?
Historically, I haven't hurt my back, although when I saw the GP before
they did say that I might have sciatic pain.
And how long ago was that?
Probably a year ago now.
I see. So you've definitely been sitting there for a while now.
Some very specific questions that are going to help me know what we're going to do
with regard to the back pain.
Have you had any pins and needles to the feet?
No, not at the moment.
When you go to the toilet to wipe your bottom,
is there any numbness to your buttocks?
I did feel like sometimes I don't feel like I'm actually wiping myself.
Maybe that is the numbness.
Okay, that's important, thank you.
And how are you doing passing urine?
I'm finding I'm having to go quite frequently, actually.
I think that's probably because I don't feel like I've completely emptied my bladder every time I go.
Okay, how long has that been for?
Actually, that's only been going on in the last few days as well,
when the pain started getting worse as well.
I don't know if I have a UTI or something.
So prior to the pain getting worse, you could pass urine normally?
Yeah.
And now the pain is getting worse, you feel that you're not fully emptying your bladder?
Yes, that's right.
Okay, that's very important.
Staying in that region at the front, have you noticed any numbness to your genitals?
Not that I've noticed.
Okay.
And a very personal question.
Obviously, we've talked about your waterworks chest.
Do you have any problems opening your bowels?
In the last few days, I haven't really opened my bowels.
Okay.
In the last three days.
So prior to that, when you were wiping, did everything feel normal when you wiped?
Prior to everything, yes.
Normal sensation?
Normal sensation.
Thank you for that.
I'm just going to zoom out a little bit and ask some questions about you as a person overall.
Do you have any medical problems at the moment?
Apart from the sciatic pain, not really, no.
And any previous surgical problems?
No, none.
Are you taking any medications?
You mentioned paracetamol.
Yes, yeah.
I think the doctor did prescribe me some pregabalin.
Okay.
And are you taking any over-the-counter medications?
No.
Okay.
Do you have any drug allergies?
No, no drug allergies.
Do you have any allergies generally?
Oh, no.
I think I was allergic to probably soy or something, but that's it.
Okay.
So obviously we've got this back pain.
It's clearly affecting you as a person.
What is it you do for work?
I actually work as a finance manager.
Okay.
And how is it affecting things there?
Well, I'm having to sit down quite a lot, so it's not helping with the pain, really.
I try to sort of move around, but it doesn't really help whether I'm sitting down or up.
But it does seem to get worse, actually, now that you mention it, when I'm staying in a static position as well.
So in terms of working out where we're going to go, I'd just like to ask some personal questions, if you don't mind.
Do you drink alcohol?
Occasionally.
Probably just a glass of wine or something over dinner if it's a special occasion.
Okay.
So how often might that be?
Probably like once a month.
Okay.
And do you smoke at all?
I don't, never have.
Okay.
And have you ever used recreational drugs?
No, never.
Okay, thank you.
So you said that you thought this might be sciatica.
Obviously it's getting worse.
What's worrying you about this at the moment?
Well, I think what's worrying me the most is the weakness, because that's kind of new.
I've had this sort of sciatic pain for at least a year now, but this weakness in my leg is very different.
Yeah, that's what's worrying me the most.
Okay.
Now I've got an idea of what we're going to do, but nevertheless I want to make sure that we're all on the same page.
Was there anything specific that you were hoping we'd do today?
Well, I just hope maybe I can get a scan or something of my back, just to make sure that nothing else is going on.
And if nothing else is going on, then maybe just some stronger painkillers.
Okay.
So what we're going to do, we're going to get you to lie down on the couch at the moment, and we're going to do an examination.
Because of what you're talking about, that is going to involve doing a rectal examination.
Are you happy to proceed with that?
Yeah.
Super.
I'll go and get the chaperone in a moment.
So what I'm thinking about at the moment, I think this could be a problem with your spine.
So if we substantiate that with any of the examination findings at the minute,
then I think actually speaking to the hospital department to get you seen today,
potentially with a scan, maybe doing a scan of the bladder, because you're saying things weren't completely empty,
or maybe doing a scan of your back as well, we'll be able to work out what's going on.
Okay.
Let's go do the examination.
Absolutely.
