It's Twos Day

You've probably seen all over the internet and social media that today is Two's Day. The date is 22022022. It is a palindrome and an ambigram. You can read it from left to right, right to left, and upside-down. Except for that, there was nothing spectacular about this Tuesday. 

The day started with a continuation of the Neurosurgery case-based seminar that I typically have on Tuesday mornings. The Neurosurgical Fellow leading the class shared with us case number four. We were given the following information...

A 42-year-old male patient attends the A&E with a 12-hour history of severe lower back pain and leg weakness commencing after lifting a heavy load at work. The pain radiates from the lower back to the right leg and he has found it increasingly difficult to walk. The patient has had one episode of urinary incontinence and complains of intermittent numbness 'down below.' The patient has no complaints of weight loss, fever, or night sweats. The patient has no past medical history. The patient works as a builder and has a 20 pack-year history of smoking. 

Vitals: HR 102 bpm, BP 125/80 mmHg, RR 18 bpm, T 36.8 degrees C, O2 Sat 98%

Physical examination: Cranial nerves and upper limbs - normal, Lower limbs - straight leg raise positive 15 degrees right side, power 5/5 in hips, knees, and ankles, 3/5 in right extensor hallucis longus, numbness on dorsum of right foot. Digital rectal examination - normal anal tone, perianal numbness.

Together, we analysed the patient history. Taking it a sentence at a time, I'll share a breakdown of how we did this.

A 42-year-old male patient attends the A&E with a 12-hour history of severe lower back pain and leg weakness commencing after lifting a heavy load at work.

This should make you think of slipped disks as a diagnosis. 

The pain radiates from the lower back to the right leg and he has found it increasingly difficult to walk.

This should make you think of sciatica as a differential diagnosis.

The patient has had one episode of urinary incontinence and complains of intermittent numbness 'down below.' 

This should make you think of cauda equina syndrome as another differential.

The patient has no complaints of weight loss, fever, or night sweats. 

This should make you think the patient is not suffering from any malignancy.

HR 102 bpm

All the vitals were normal, besides the heart rate, which is a bit high. Tachycardia could be due to the pain that the patient is in.

Lower limbs - straight leg raise positive 15 degrees right side, power 5/5 in hips, knees, and ankles, 3/5 in right extensor hallucis longus, numbness on dorsum of right foot. Digital rectal examination - normal anal tone, perianal numbness.

This builds upon our idea that cauda equina syndrome is the diagnosis.

With the Neurosurgical Fellow, we discussed the associated investigations, considerations, and management of the patient. He asked us questions like,

1. What are some causes of cauda equina syndrome?

Causes of cauda equina syndromes include disc prolapse (L4/L5), lumbar spine stenosis, trauma (lumbar puncture, penetrating traumas), and infection/malignancy (abscess, discitis, malignant spinal cord compression (MSCC)).

2. What is the single most important step in this patient's management?
A. Analgesia
B. Post-void bladder scan
C. MRI lumbar spine
D. Refer to neurosurgery

All of these answers are important in the management of this patient, but the question asks, 'the single most important,' so the correct answer is C. An MRI lumbar spine is the single most important step in this patient's management because it will determine if the patient needs surgical or non-surgical treatment. Analgesia is important because without giving the patient painkillers we are unable to examine them. A post-void bladder scan is important because it helps to determine if there is urinary retention. A referral to neurosurgery will depend on the results of the MRI lumbar spine. If there is a compression lesion that the surgeons can remove, then the patient should be referred to the neurosurgeons for decompression surgery. 

The next question we were asked was,

3. How can you diagnose cauda equina syndrome?
This is a tough one. Cauda equina syndrome is a clinical diagnosis, characterised by dysfunction of the bladder, bowels, and sexual function, and sensory changes in the saddle of the perianal area. Other possible symptoms include back pain (with/without sciatic-type pains), sensory changes or numbness in the lower limbs, lower limb weakness, reduction or loss of reflexes in the lower limbs, and unilateral/bilateral symptoms.

When we finished this case, the Fellow presented another. We only got halfway through the case before the class time ran out, but we will continue it at our final session next week. 

It was once again an interactive class and I believe the highlight of my day. I enjoy these seminars and the way the cases are presented. I think the latter is mostly because the fellow is a really great teacher. I may have shared this once before but I'll say it again, I love that these seminars allow me to put into practice the theory of Neurology. As medical students, we always underestimate our knowledge. Daily studying and constant revision keep things fresh, but these kinds of sessions are also useful in testing knowledge and help me to build confidence in my abilities.