Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

The aim of this study was first, to determine whether CT scans undertaken to identify serious injury to the viscera were of use in detecting clinically unrecognised fractures of the thoracolumbar vertebrae, and second, to identify patients at risk of ‘missed injury’.

We retrospectively analysed CT scans of the chest and abdomen performed for blunt injury to the torso in 303 patients. These proved to be positive for thoracic and intra-abdominal injuries in only 2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a fracture of the thoracolumbar vertebrae and these constituted our subset for study. There were eight women and 43 men with mean age of 45.2 years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable fractures. Only 17 fractures (33.3%) had been anticipated after clinical examination. Of the 22 unstable fractures, 11 (50%) were anticipated. Thus, within the whole group of 303 patients, an unstable spinal injury was missed in 11 patients (3.6%); no harm resulted as they were all protected until the spine had been cleared. A subset analysis revealed that patients with a high Injury Severity Score, a low Glasgow Coma Scale and haemodynamic instability were most likely to have a significant fracture in the absence of positive clinical findings. This is the group at greatest risk.

Clinical examination alone cannot detect significant fractures of the thoracolumbar spine. It should be combined with CT imaging to reduce the risk of missed injury.

Purposes of Study and Background: To survey beliefs and attitudes about the management of mechanical back pain in General Practitioners (GPs) in two cities in the East Midlands, and to compare the findings with a similar recent Australian study. We also conducted a ‘found experiment’ on the use of ‘The Back Book’ by the GPs in the two cities following the purchase and distribution of its copies to the GPs in Leicester by the local Primary Care Trusts.

There has been a paradigm shift in the management of mechanical low back pain in the last ten years. Several different clinical guidelines are available based on current evidence in the literature. There is little to show how far these guidelines are being implemented. There are no studies of the barriers to implementation in the British population.

Methods and Results: A postal questionnaire consisting of ten questions, eight of which were taken from a questionnaire used in a similar survey from Australia. Two additional questions relating to the ‘Back Book’ were included. 164 GPs in the city of Leicester and 353 in the city of Nottingham were surveyed in August – September 2001.

The response rate was 70.1% (115) from Leicester and 65.7% (232) from Nottingham. The majority of GPs from both cities were aware of the current concepts about the management of mechanical back pain. The awareness and usage of “The Back Book” was significantly better amongst the GPs in Leicester (p < 0.001).

Conclusion: General practitioners in two cities in Trent region are well aware of current best practice in the management of acute back pain. Their attitudes and beliefs towards back pain management compared well if not better in some aspects, with those of their Australian counterparts. If the resource of ‘The Back Book’ is made available then GPs will use it, in keeping with current best evidence.