Sagittal view Mr X was referred to the Triage service with a history of back pain with some radiation down the leg in the pattern of sciatica. A triage appointment was made for 16 days after the date on the referral form.
During this period the patient's symptoms changed. He began to develop sciatic symptoms in the other leg and some sacral numbness. In addition he reported, when he reattended his GP surgery, that he had had prostatic surgery a few months before. Following this his urinary stream had improved, but since the back pain had developed this had deteriorated once more.
He was seen by another partner in the practice, who faxed an urgent letter to the rheumatology department which was received late on a Thursday afternoon. It was seen by one of the consultants who was on leave on the Friday, but arranged to see the patient on the following Monday morning.
The patient attended at 9.45am. Although he was ambulant and not in great distress, the consultant agreed that the further development of symptoms might represent a cauda equina syndrome. He sought an urgent MRI scan. This was performed just under one hour later.
The result showed degenerative changes with a tight stenosis at the L3/4 level, possibly aggravated by a small disc protrusion. The consultant considered that the current symptom level warranted conservative management; as the patient had a booked triage appointment two days later with the physiotherapy specialist, this was confirmed to start a short trial of traction. He discussed the possible outcomes with his physiotherapy colleague so that failure would be followed by urgent surgical referral. The patient was meanwhile warned to report any significant change in sensory loss or bladder symptoms.
The scans are shown below. The sagittal view shows the stenosis clearly, while the cross-sectional views clearly indicate the marked trefoil narrowing (scan 37) at the L3/4 level.
Sagittal view
Series at L3/4
Compare these enlargements of scans 34 and 37 (top and bottom middle) to see the marked difference in shape of the spinal canal