Dr Ramos-Galvez Discusses ‘The Back of Litigation’ In the March Issue of Your Expert Witness Magazine

26 Jan 2018


By DR IVAN RAMOS-GALVEZ LMS, FRCA, FFPMRCA, Consultant in Pain Medicine at Medicolegal Associates Ltd and Spire Dunedin Hospital.

The lower back is the area of the back situated between the inferior border of the rib cage and the creases of the buttocks. At any given time, 33% of the population will suffer from lower back pain. Over a one year period this increases to 65% and across a lifetime, 84% of us have at some point suffered from it. However, only 20% of sufferers will attend their GP to seek treatment or advice. Overall, this means approximately 2.6 million people in the UK annually will consult their GP. Lower back pain is more prevalent in women in their 30’s onwards.

The natural progression of lower back pain when treated is one of rapid improvement both in pain and disability over the first month, clinically, there is very little change after the third month. However, 62% of sufferers still complain of lower back pain 1 year after the onset of the first episode. More worryingly, 16% of those unable to work as a consequence of the initial episode will not have returned to work 1 year later.

Lower Back Pain in a Medico Legal Case

When contemplating a personal injury claim, by virtue of the statistics, the likelihood is that claimants would have suffered lower back pain before the index event. With only 20% of back pain sufferers consulting their GP, primary care records are not always an accurate reflection of their previous level of fitness. Only the experience and knowledge of an expert witness can untangle this conundrum.

In suspected clinical negligence, early involvement from an expert is vital when preparing to issue the claim. The expert can help to target key indicators in the case as well as identify weak areas which require further investigation. This can reduce costs and manage the claimant’s expectations.

The challenge for the clinician when confronted with a relapsing patient is to establish whether this is a new episode in recurring back pain or a completely new problem manifesting itself as back pain?

Whilst the tendency is to blame it on the historic non-specific lower back pain returning for yet another crippling episode, care and consideration have to be exercised in order to exclude a potential new diagnosis.

Malignancy, infections, inflammatory processes, trauma and wear-and-tear have to be considered depending on the presentation of the current condition as well as age group, other co-morbidities and associated symptoms. If the symptoms persist, and more importantly deteriorate, the threshold for a revised diagnosis has to be lowered.

Effects on the Patient

An easy error to be avoided is over-investigating and over-medicalising the process. This could potentially lead to a serious situation where any change in a repetitive pattern will be met with the expectation of a full set of investigations to be promptly delivered. Patients may resort to “doctor-shopping” in the quest for a diagnosis, for someone who will sell them hope in the shape of pioneering treatments or treatments only they perform!

The situation for most of these patients is therefore complex. They feel pain and may experience disability as a result which cannot be seen by those around them. The understanding and support they receive in the early stages tends to fade over time and they can feel isolated and that nobody believes them. This is the point when they can fall into a downward spiral of low mood and self-esteem making them feel worthless.

At the other end of the scale, some patients try to keep things as normal as possible and they soldier on pushing themselves and suffering the consequences in the shape and form of frequent relapses. These will eventually join the previous group in the downward spiral.

There is a third group of sufferers whose support network invalidate them and their efforts completely and take over all the activities on account of their “disability”. These patients can suffer from “enabling families” promoting a secondary gain that can be financial or affective.

The Role of an Expert

The appropriate management of back pain is a multidisciplinary approach involving close co-operation between primary and secondary care practitioners. This will include pain specialists, spinal surgeons, rheumatologists, general practitioners, physiotherapists, clinical psychologists, clinical specialist nurses, occupational therapists, osteopaths all of whom play an important role.

Needless to say, the opportunities for litigation can arise at all points throughout this long journey. There may be a case of clinical negligence due to a missed diagnosis or a treatment perceived as “going wrong”. Or, a case for a personal injury claim when a fall, a slip, a road traffic accident… results in persistent low back pain.

The role of an expert can be vital to differentiate what could be a complication against a negligent action. The expert can offer insight into an uncommon presentation of an unusual disorder which, by virtue of its rarity only a very specialised unit may have been expected to investigate, diagnose and treat. They will also help to differentiate what might be a case of exaggeration of symptoms against a genuine claim and provide valuable insight for decisions related to acceleration of long-standing injuries against expected wear and tear.

Importantly they can provide a prognostic opinion both in terms of resolution of symptoms and in terms of likelihood of the patient returning to the pre-existing level of function.

Dr Ivan Ramos-Galvez is a consultant in Pain Medicine with a sub speciality in spine surgery at the Royal Berkshire Hospital and Spire Dunedin Hospital in Reading, Berkshire. If you are interested in instructing Dr Ramos-Galvez, do not hesitate to contact us.