Accident or providence? Communication is key in every case

With increasing workloads in healthcare and evergrowing reliance on technology in medicine, it seems we are spending less time actually talking to patients; but, as American neurosurgeon and author Dr Frank Vertosick Jr once wrote: “Listen to the patient, they are telling you the diagnosis.” Communication is more important than ever.

A back injury while overseas

A recent Mayday case in January 2024 highlighted this clearly, and reminded me of those words. A 62-year-old with preexisting hypertension tripped on a tiled floor in her apartment in Cordoba, Spain, landing on her back and experiencing immediate mid-thoracic back pain.

She presented to a nearby hospital, and spinal X-rays were carried out. Her clinical examination was essentially normal – the X-rays were reported as showing no fractures, and she was deemed to have sustained a simple muscular injury, was discharged and declared fit to continue her travels and to fly back to the UK with her husband. As such, she continued her holiday – travelling on to Seville, walking the city and dining out, and seeing out the remaining two weeks of their stay.

Documents requested – but not received

Mayday requested to see the patient’s X-rays, as well as X-ray reports (as per our protocol, to be sure of no discrepancies between the two), but these were not forthcoming. We spend huge amounts of time and effort pushing to obtain radiological images from around the world. This process is typically fraught with obfuscation on the part of treating hospitals, and sometimes it is only by requesting via patients that we ever receive them.

On this occasion, in spite of our usual efforts, we received no images, and were left with a patient who naturally wanted to continue travelling, and with no apparent reason not to. Our operations and medical team nonetheless stayed in regular communication with the patient post-discharge, and during such communications it became apparent that her back pain was not going away. Unremitting back pain – a symptom that sets alarm bells ringing for any spinal surgeon.

Returning to hospital

We advised her to go straight back into hospital in Seville for repeat imaging, providing her with our own request form to take straight to radiology. Later that day, on trying to track her down, we found that she had been admitted straight from the scanner into a neurosurgery inpatient bed.

The scan had revealed a severely crushed T4 vertebral body with a surrounding haematoma and a retropulsed bone fragment abutting her spinal cord. Most fortunately, she had developed no neurological deficits, and had sustained no spinal cord injury while dining out with this injury.

In addition, the scan revealed a previously unknown significant aortic aneurysm, 4.2cm in diameter, in her ascending aorta. How the T4 injury was missed on the initial imaging was unclear.

Operations and repatriation

We discussed the situation with the Seville neurosurgeons; the patient was prepped and underwent spinal decompression and fixation with rods and screws from T1 to T7. After several post-operative days of hypertension, bladder infection and feeling weak, she started to recover and mobilise.

Soon after she was successfully commercially repatriated back to Worcestershire for spinal follow-up, and, importantly, for vascular follow-up to manage the newly diagnosed aortic aneurysm.

Conclusion

In spite of the initial reported clean bill of health, we continued to talk and listen – the patient was telling us of an unknown diagnosis; and, perhaps most crucially, but for this seemingly innocuous fall onto her back, the incidentally discovered aneurysm would have continued its sinister march towards catastrophe, unseen and unchecked.