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The back pain problem

Case history 3

Miss Whiplash is a 35 year old divorced mother of two in your practice, who has a part time job on the checkout at a local supermarket. She has attended the surgery in the past in intermittent bouts, her general health being good, but her stress levels being fairly high, particularly in association with her unsatisfactory marriage and financial difficulties since. Her fifteen year old daughter rings the practice to ask for a home visit, because her mother is "in bulk". She was involved in a car crash two days earlier.

On arrival at the home you see the car in the drive with a fair sized dent in the back, but obviously still driveable. Miss Whiplash is lying on the bed upstairs, grimacing in pain, and looking very stiff. She tells you that the accident occurred whilst driving home from work two days ago, and that she was fine until yesterday morning when her neck pain began, and continued to get worse over the day. The pain is now spreading up into the back of the head, and over the eyes, and is both constant and severe. She feels dizzy when she tries to get up to go to the bathroom, and has pains shooting down the left arm and into the ring and little finger.

Q1. Do you require more information?

What might you look for on clinical examination?

Examination shows her to have a very stiff neck, although she can be coaxed into moving it. The pupils are normal, equal, and react to light. Reflexes are normal and equal, muscle power in the left arm appears weak compared with the right, but appears to be limited by pain.

Q2. Do you require more information?

What action should be taken?

What treatment should be recommended?

What should be explained to the patient?

The patient is sent to the local Accident and Emergency department, by ambulance. X-rays are taken of her cervical spine which are said to be normal. After three or four hours waiting for an assessment and x-rays, fortunately Miss Whiplash's pain has begun to settle somewhat, and she is given a cervical collar and analgesics, and advised to go home and rest for two days.

Miss Whiplash comes to see you a week later, complaining of ongoing neck pain, headache, and a heavy feeling in the left arm. She is continuing to use the collar, and asks for more Co-codamol and a sick note.

Q3. Do you require more information?

What action should be taken?

What treatment should be recommended?

What should be explained to the patient?

At three months Miss Whiplash is continuing to complain of pain, which has not responded to a course of physiotherapy which you recommended. She has pain and tingling in the left arm, going down to the fingers, and a heavy feeling in the arm; she has difficulty in using it. She cannot drive, because she cannot turn her head, and she has not gone back to work. She has gone to see the local Acupuncturist, and has not had any significant relief. She feels the pain is getting worse, and demands referral to see "a Specialist". She states that one of her friends has had her neck fixed by a charismatic local Orthopaedic Surgeon.

Q4. Do you require more information?

Is this a reasonable request?

The patient goes to see the Orthopaedic Surgeon, who does find some weakness in her arm and arranges an M.R.Scan which shows a cervical disc lesion at C7/T1. There is no severe cord compression and he refers the patient to the Pain Clinic, where she has a cervical epidural with good initial benefit. She suffers permanent ongoing symptoms of neck pain, and some weakness and heaviness in the left arm for a further six months. However, she goes back to work in spite of an impending litigation claim, after being encouraged by attendants on the Pain Management Rehabilitation Programme!

Continued support and encouragement, along with an optimal analgesic regime, maximise her chance of remaining mobile. Her medico-legal claim is eventually settled and she receives a payout of US$20,000. This relieves her of some of her financial worries, whilst not altering her ongoing neck pain and her slight disability in being unable to carry out sports and dance.

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