About this presentation The scenarios in this slide presentation are based wholly or partly on real patients who have presented to GP surgeries. They have been anonymised for use as a teaching tool for GPs in Training. For realism the patients have been given fictional names, ages and professions.
David Morris 39 years old Works at a Hotel as a Waiter Infrequent attender Usually well No diagnosed conditions of note Married, son aged 12
First Consultation – 20 March 2013 Saw Doctor A (GP Partner) Accidental Fall Slipped at work on a greasy kitchen floor. Fell on right side. Got up and carried on. Stiffness and bruising 48 hours later. Still has niggle of pain R loin. Examination normal. Continue nsaids should settle with time
Second Consultation – 9 May 2013 Saw Doctor B (GP Partner) Hip pain esp nocte – following a fall onto R hip 4-5/52 ago. Refer to physiotherapist
Third Consultation – 7 June 2013 Doctor B again Back pain – appt at physio end of June! Expedite letter Rx Tramadol
Entry in notes – 10 June 2013 Urine dipstick test – NEGATIVE. No sign of infection
Fourth Consultation – June 17 2013 Spoke to Dr C (ST3 Trainee), TRIAGE CALL Hip pain – since fall. Also now back pain. Suspect it is to do with walking because of hip pain. No red flags. Taking paracetamol/codeine/tramadol regularly. Works as a waiter and looks after son. Struggling. Physio next week....
Fourth Consultation – June 17 2013 Continued... Wants sick note/examination as insisting on scan. Don’t think will need it but reassess and see what u feel. c/o muscle spasms. ? Diazepam for a few days. Outcome – appt given for same day
Fifth Consultation – June 17 2013 Saw Dr D (FY2 Trainee) Hip pain – since fall 5/52 ago. Now c/o pain in lower back. Altered gait to compensate for R hip pain. No red flags. No neuro symptoms. Tramadol stopped, didn’t help. can’t sleep due to pain.
Fifth Consultation – June 17 2013 Examination – tender ant joint line R hip. Feels like there is a deep haematoma in R thigh. No SIJ tenderness. SLR ok, good ROM, some lower back spasm. No neurology. Keen for scan – explained why this is not appropriate. Rx Codeine 30 mg, diazepam (2 mg x 28). Aware of red flags. To return if present. MED3 2/52 ACUTE BACK PAIN
A search of the literature has shown that 163 Red Flags for sinister back pain have been identified!
Referred pain that is segmental or band-like Escalating pain which is poorly responsive to treatment (including medication) Different character or site to previous symptoms Funny feelings, odd sensations or heavy legs (multi- segmental) Lying flat increases pain Agonising pain causing anguish & despair Gait disturbance, unsteadiness, especially on stairs (not just a limp) Sleep grossly disturbed due to pain being worse at night RED FLAGS FOR METASTATIC SPINAL CORD COMPRESSION Greenhalgh & Selfe 2009
Past Medical History of Cancer (but note 25% of patients do not have a diagnosed primary) A Combination of Red Flags increases suspicion (the greater number of red flags the higher the risk and the greater the urgency)
Sixth Consultation – June 26 2013 Saw Dr E (GP Partner) Back pain – weakness right leg, sensation loss laterally and reduced knee jerk. Needs scan, if worsens for immediate review, bowel and urinary function ok and no sensation loss in perineal area. Rx Co-codamol, Naproxen MRI SCAN REFERRAL (Lumbar spine)
Seventh Consultation – July 1 2013 Spoke to Dr F (ST3 Trainee) Needs MED3, saw Dr E last week. No bladder or bowel symptoms, no numb bum. MED3 2 weeks – Back pain
Eighth Consultation – July 4 2013 Spoke to Dr G (GP Partner) Leg pain worse, numbness spread round from top of leg from lateral aspect to inner. No bowel, bladder symptoms, no parasthesia or weakness other than this. Already referred MRI Scan. Advised re cauda equina symptoms Management plan is sound
Cauda Equina Syndrome Cauda Equina syndrome is caused by compression of nerve roots distal to the level of spinal cord termination (Usually L1/L2) Trauma, vertebral fracture or displacement, disc herniation, a tumour or metastatic deposit or an abscess Permanent neurological damage can occur
Cauda Equina Syndrome Low back pain and: Bladder dysfunction, usually retention. Sphincter disturbance Saddle anaesthesia Lower limb weakness Gait disturbance The symptoms and signs depend on the level of compression
Pain and Deficits Associated with Specific Nerve Roots
Ninth Consultation – July 15 2013 Spoke to Dr E MED3 – back pain with neurological involvement, 2 weeks Tenth Consultation with Dr E 31 st July MED3
Eleventh Consultation – August 12 2013 Spoke to Dr H (GP Partner) MED3 – back pain with neurology, 2 weeks
22 August 2013. Dr A, logged on at home reading routine letters
MRI REPORT LUMBAR SPINE 14 August 13 Diffuse abnormal signal of the bone marrow and large right and paravertebral soft tissue masses. Consistent with tumoural process. Consider lymphoma. Encasement of right L3 and L4 nerve roots Encasement of the right ureter with secondary hydronephrosis
Did the Scan result fit with the clinical symptoms?
Consultation with Dr A, 23 August 2013 12 th consultation, was asked tci urgently Breaking bad news, at end of morning clinic Came with his wife Possibly lymphoma This is a type of cancer Already spoken to Haematology Consultant and arranged appt next week Next step is a biopsy
Consultation with Dr A, 23 August 2013 David: “So all this has been caused by a slipping in the kitchen?!”
Summary of Timeline Date and DoctorDiagnosis CodeOutcome 20 March, Dr AAccidental FallShould settle with time 9 May, Dr BHip PainPhysio referral 7 June, Dr BBack PainExpedite Physio, Rx 17 June, Dr CHip PainGiven appt tci 17 June, Dr DHip PainAnalgesia, request for scan declined 26 June, Dr EBack PainMRI SCAN lumbar spine referral 1 July, Dr FBack PainMED3 4 July, Dr GLeg PainAdvice re: cauda equina symptoms 15 July, Dr EBack PainMED3 31 July, Dr EBack PainMED3 12 August, Dr HBack PainMED3 14 AugustHAD MRI SCANFaxed to surgery 22 August, Dr ARead reportAppt next day to discuss result
Letter from Haematologist – 1 Oct 2013 Well, paresthesia on thigh has resolved No lymphadenopathy CT-Guided Biopsy Result – Diffuse Large B- Cell Lymphoma Treatment – To have Chemotherapy
Victor Parker 66 Moderate COPD, borderline DM On Seretide and Spiriva inhalers Ex-smoker Retired Joiner Lives with wife
Consultation No. 1 I‘ve got pain in my back! It came on over the weekend I had been stretching up to paint the ceiling Its really sore Its next to my right shoulder blade Examined: no bony tenderness Conclusion: likely to have strained back by painting ceiling Analgesia Rx. Co-codamol 30/500 See again if worsens
Consultation No. 2 later that week The doctor said to come back if it got worse It has got worse, the co-codamol are not helping Examined: tenderness over the right side of upper thoracic vertebra Outcome: Rx Tramadol. Refer for MRI Scan of thoracic spine Differential diagnosis ? This Dr ordered an MRI scan to investigate, but what would you do?
Myeloma: 2008-2010 Average Number of New Cases Per Year and Age-Specific Incidence Rates per 100,000 Population, UK Please include the citation provided in our Frequently Asked Questions when reproducing this chart: http://info.cancerresearchuk.org/cancerstats/faqs/#How Prepared by Cancer Research UK - original data sources are available from http://www.cancerresearchuk.org/cancer-info/cancerstats/
What is Multiple Myeloma? Plasma cell in Bone Marrow becomes malignant Plasma cells are a type of WBC Plasma cells usually produce immunoglobulins (antibodies) Plasma cell clones multiply and accumulate in bone marrow Immunoglobulins (antibodies) are also known as ‘paraproteins’ The malignant plasma cells make vast quantities of Ig’s = paraproteinaemia
Myeloma Disease Process The type of paraproteinaemia depends on the type of plasma cell which became malignant Commonest is IgG Myeloma The plasma cell tumours are known as plasmacytomas, they spread and damage bone affecting multiple areas of the skeleton This causes hypercalcaemia The paraproteins cause renal damage
Myeloma can lead to..... Pathological fractures Nerve compression Renal failure Bone pain Hypercalcaemia symptoms Anaemia Thombocytopaenia Serious infections (only 1 type of Ig) Hyperviscosity
MYELOMA SCREEN Full blood count ESR or plasma viscosity Urea, Creatinine, Calcium, Albumin Electrophoresis of serum and concentrated urine including 24 hour Urine for Bence-Jones Protein light chains (typical antibody = 2 light chains + 2 heavy chains) +/- Xray of painful region, lytic lesions, pathological fractures
What is the Treatment for Myeloma? Young patients who can tolerate aggressive treatment – Stem Cell Transplant (autologous or allogeneic) Following 6-9/12 treatment with: Chemotherapy + Steroids +Thalidomide Older patients >70: mephalan, pred & thalidomide (MPT) Treatment for 12-18 months, 80% respond, well for 2-3 years and then relapse
Thalidomide Recently approved for use in combination with steroids for the treatment of newly diagnosed Multiple Myeloma Interferes with signals affecting myeloma cell multiplication and spread Inhibits new blood supply (angiogenesis) Patients must not become pregnant or father children on treatment with thalidomide
Victor Parker – Home Visit Request 2 weeks later at 11:30am His wife rang: ‘Can you come and see Vic, He tried to get up to go to the loo this morning and he says his legs are too weak! He stumbled on the stairs yesterday and he’s got pain in the bottom of his back’
Victor Parker – Home Visit Request The Doctor visits straight away: Back Pain: Unable to stand due to weakness of legs. Unable to pass urine into container by bed, ?bladder palpable. no ankle reflexes and loss of sensation to perineum/perianally. Poor anal tone. Spoke to Neurosurgeons at Hope ? Cauda Equina Syndrome
Victor Parker - Outcome Radiology report in hospital L5 vertebral collapse causing compression of cauda equina, partial compression fracture of T6 noted, no cord compromise at this level, multiple lytic lesions of spine and ribs, consider myeloma as first differential. report phoned to neurosurgery team – for urgent decompression at L5/S1
Victor Parker - Outcome Had decompression surgery Spent 3 weeks in hospital Still has leg weakness but normal bladder function Myeloma was confirmed – chemo, steroids, thalidomide Whilst in hospital appointment came through for MRI arranged by GP Shortly after discharge his wife (and main carer) had a sudden episode of drooping of left side of mouth with an irregularly irregular pulse...
Mr Bob Peters 83, Type 2 DM 23 June 2014 – left-sided low back pain and hip pain (chronic) Examination of hip and back normal No bony tenderness OA lumbar spine likely Analgesia advice – add codeine to paracetamol
21 July 2014 Diarrhoea symptoms 1 month Loss of appetite Loss of 1 stone in weight in 1 month PR normal Abdo exam normal FH Bowel Cancer Referred for colonoscopy 2WW
13 August 2014 Colonoscopy normal 17 August Attended OOH GP – fever, malaise, dysuria No urine to dip, T 37.8, tender suprapubically Suspected UTI Trimethoprim 200mg bd 7 days
22 August 2014 Reviewed following OOH GP attendance Symptoms better but feels drained Urine dipstick normal, T 36.9 No signs of ongoing infection Antibiotics finish today Recovering from illness
8 September Still not fully recovered from UTI, feels lethargic Still has back pain, slightly worse. Bloods arranged inc PSA, Bone profile, CRP, UE eGFR, FBC, HbA1c, LFT
24 September 2014 Blood results PSA 47 (< 6.70 ug/L) Hb 12.7 HbA1c 48 ALT 37.4 (<5) CRP 37.4 (<5) eGFR 63, creatinine 110 (62-124) ALP 141 (<130) Other blood tests parameters normal
26 September 2014 Results discussed with patient Prostate Cancer likely Referred Urology 2WW 3 October Emergency appointment Severe left-sided back pain, loin to groin, colicky Apyrexial, abdomen soft, feels pain in renal angle Referred surgeons ? Renal colic
CT Scan during Admission Suggestive of prostate cancer with nodal involvement Filling defect in left sided renal pelvis Diagnosis: Ureteric obstruction secondary to prostate cancer Biopsy done Started on Cyproterone and to have Zoladex in clinic
Managing Neuropathic Pain NICE GUIDELINE CG96 (Health Technology Appraisal) 1. Amitriptyline or Pregabalin 2. Pregabalin (if 1 st used was Amitriptyline or other TCA) 3. Refer to Pain Team and add or change to Tramadol Don’t start opoids other than Tramadol without specialist assessment LOCAL GMMMG GUIDELINE 1.Amitriptyline 2.Nortriptyline/imipramine to maximum doses 3.Gabapentin 4.Pregabalin (if started 1 st and not effective go back to step 1) 5.Carbamazepine or other anticonvulsant
GMMMG Guidance GMMMG met and considered the NICE guideline CG96. (without access to the evidence NICE considered) NICE places products equally in the guideline when there is an acquisition cost difference of 20 – 60 times difference per month. Implementation of the guideline would have lead to an additional financial pressure of £12.8 million
Drugs licensed for treatment of neuropathic pain
Response from NICE NICE is aware that there have been concerns about the associated costs that pregabalin may bring to the NHS as one of the first line treatment options for adults with neuropathic pain Therefore, NICE will fully update its clinical guideline in order to address ongoing uncertainties regarding the cost effectiveness of some of the recommended treatment options Until a further announcement is made, the original guideline (CG96) continues to represent best practice for the NHS
The Back Book (RCGP) http://www.wsib.on.ca/files/Content/DownloadableFil eTheBackBook/BackBookEnglish.pdf
Upcoming Sessions 11th November 2014: Confidentiality and Consent (MDDUS) 25th November 2014: TBC 9th December 2014: COPD (Michaela Bowden)