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Histories

Back Pain | MRCS Part B OSCE Revision

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Clinical Scenario

A 45-year-old woman with a 5-year history of lower back pain attends clinic. An MRI 4 years ago showed mild degenerative change and there is no history of trauma. Over the past 3 days the pain has become suddenly and severely worse, and now radiates down both legs. She cares for a disabled husband at home and is under financial pressure to keep working.

Take a focused history, then discuss your diagnosis, investigations and management.

Related Differentials · Same Topic
The examiner could set this station around a different diagnosis within the same presenting complaint. Know how each would change the history.
Differential What would point to it in the history Management in brief
Cauda equina syndrome (this case)Bilateral sciatica, saddle anaesthesia, bladder/bowel incontinence, progressive leg weaknessCatheterise, urgent MRI whole spine, immediate spinal referral → urgent decompression within 24–48 h
Lumbar disc prolapse / sciatica (no red flags)Unilateral dermatomal leg pain, positive straight-leg raise, normal bladder and bowelConservative: analgesia, stay active, physiotherapy. Surgical: microdiscectomy if >6 weeks or progressive deficit
Metastatic spinal cord compressionKnown cancer, weight loss, night pain unrelieved by rest, upper motor neurone signsDexamethasone 16 mg, urgent MRI whole spine, oncology → radiotherapy ± surgical stabilisation
Discitis / spinal epidural abscessFever, raised CRP, IV drug use or recent infection, exquisite spinal tendernessBlood cultures, MRI, IV antibiotics; surgical drainage if abscess or neurological deficit
Mechanical / functional back painPain on movement, eased by rest, no red flags, previous similar episodesConservative only: analgesia, stay active, physiotherapy, avoid bed rest. No surgical role
Ankylosing spondylitisYounger patient, >30 min morning stiffness improving with exercise, enthesitis, uveitisNSAIDs, intensive physiotherapy, anti-TNF therapy. Surgery only for established deformity
Non-spinal (AAA, renal colic, pancreatitis)Abdominal or flank component, pulsatile mass, vascular risk factors, colicky loin-to-groin painTreat the cause — ruptured AAA is an immediate vascular emergency; CT for renal colic and pancreatitis

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