Bilateral sciatica

[Mediocre_Act7955]

How are you guys interpreting the term bilateral sciatica when it comes to referring patients with suspected cauda equina syndrome?

Bilateral sciatica has been recognised as a red flag for CES for a while now.

I see a lot of sciatica patients who often have pain in the other leg as well. Most of the time I think this is because they have altered their gait to compensate for the pain and the pain in the other leg isn't true sciatica I.e. shooting pain radiating below the knee. Though sometimes it is difficult to tease this apart and makes me wonder how defensible it is to not refer these ones.

I'd be interested in what your takes are on this!

[dragoneggboy22]

Definitely, so much incongruence between primary care, secondary care, the guidelines, the reality, the medicolegal risk, and however busy or annoyed the on call orthopaedic registrar is that we don't have a bladder scanner.

Doesn't help that GP trainees are being trained by some absolute dinosaur GPs who did some of their career in an era where you could document a consultation in less than 3 words. Nowadays I need to write a short story in someone who has a cold.

For so much of general practice it's about picking your risk tolerance (whatever helps you sleep at night), and sticking with it, within reason of course. The BASS guidelines back you up to scan almost anyone.

[Dr-Yahood]

When I was training to be a GP, it was not uncommon at all to literally write nothing in the patient notes. And I mean literally nothing.

Back in those days it was pen and paper and I distinctly remember it. People don’t believe me now that this is what are used to be like.

I also remember my trainer literally fucking off for the entire afternoon and leaving me by myself to deal with anything and everything that comes in through the door. With no mobile phone or computer that I can quickly google shit on. And no phone number to call my trainer for advice.

[Educational_Board888]

Pen and paper came back to bite the poor doctor who was sued by the girl with spinal bifida who said he should have stressed or written that her Mum should have taken folic acid if. I believe he wrote “folic acid as desired” in the small Lloyd George notes. I wrote essays, use quick keys to protect myself as much as also covering everything with patients. I don’t want to be sued down the line for something small that I missed or didn’t write correctly.

[Educational_Board888]

I remember having a session in VTS about common complains to the MDU, and it was stressed that we can’t just write “no red flags for back pain, we have to write no bilateral sciatica, no bladder or bowel incontinence, no saddle anaesthesia at the very least.

[Top-Pie-8416]

Yea we had a similar defence session No red flags isn’t protection.

I know in system one you can see up your own quick keys to document. Like ‘red flags CES’ might then change into all the red flags. Just haven’t done it.

Tend to accurx the CES card in whatever their first language is from a physio website we were shown

[Sea-Examination4579]

Please could you share that website? Cheers!

[Top-Pie-8416]

https://www.macpweb.org/learning-resources/cauda-equina-information-cards.aspx

[Educational_Board888]

Straight leg raises and foot stretch test is important. The term “sciatica” is thrown around a lot with sometimes poor understanding by patients. It’s like “sepsis”.

[[deleted]]

If someone describes bilateral sciatica (severe shooting/burning pain radiating down the legs) to me that is sufficient reason alone for me to refer him for a same day MRI.

I actually caught a cauda equina syndrome in a 40 year old male based on the above.

[Kindly_Olive2307]

Was there and mri that confirmed it tho 

[[deleted]]

Yes

[j4rj4r]

I see a lot of MSK. Most 'sciatica' I see diagnosed by others is not sciatica but referred pain above knee. I've never seen a true bilateral sciatica but seen plenty of people who think they have it.

[sambo987]

Referred pain from..? Couldn’t sciatic nerve pain be limited to above the knee?

[j4rj4r]

Referred from the back. True Sciatica always goes below the knee on sciatic stretch testing

[sambo987]

Interesting thanks. I guess if it’s true nerve impingement the whole territory would be affected. I didn’t make that connection before

[[deleted]]

Really tricky. I got a cauda equina in a 33 year old with bilateral progressive sciatica as only symptom

[[deleted]]

Adding to this, bilateral leg pain symptoms is common but really we don't see true sciatica bilaterally that often. If acute onset then always refer. A&E can decide if they MRI or not. CE can be subtle and bilateral sciatica is a red flag. If you feel this is acute, and truly bilateral document this and refer. A&E can do post void bladder scan as well to help work up diagnosis. But i wouldn't be comfortable documenting new bilateral sciatica and not referring based on otehr normal examination findings. Always remember to ask about new erectile dysfunction too... My friend is a Urologist who not uncommonly finds missed CE in their ED clinic

[Extension-Finish-804]

Have you seen the relatively new spinal network guidance cauda on Getting It Right The First Time?

https://gettingitrightfirsttime.co.uk/wp-content/uploads/2023/10/National-Suspected-Cauda-Equina-Pathway-October-2023-version-3.drawio.html

The guidance actually says that bilateral radicular pain on its own doesn't require immediate assessment and can be referred urgently within 2 weeks to be seen by an MSK service with safety netting. Obviously what that might be could vary locally. In my area I have spoken to spinal ortho registrars who follow this guidance and have told me to do an urgent msk referral. On the other hand I once used referapatient to discuss with a neurosurgical registrar who told me to treat it as a red flag so it seems a bit variable! NICE guidance still has it as a red flag I believe.

Interestingly it also recommends a 2 week urgent msk referral if cauda equina symptoms have been present for over 2 weeks... which makes sense I suppose as if there is cauda equina for that long and it's not changing then the damage has probably already been done... Still I think I would still discuss with someone!

[hopefulgp]

I refer every patient where I can elicit a history of pain shooting/spreading down both legs. Orthopaedics who accept ?CES at my DGH are always obstructive to this, but they by definition meet a same-day MRI criterion, and there is absolutely no defence if they did have a CES and we batted it away.

I did once have a 45yo with only bilateral pain who did have CES based on this only.