Trust A
20. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
Surgical intervention/ pain management
21. Mrs A says Trust A decided she was not suitable for surgical intervention in January 2019, which she disagrees with. She says she believes she should have been offered surgery for her spinal stenosis. Spinal stenosis is a narrowing of the spaces within the spine, which can put pressure on the nerves that travel through the spine. Mrs A says instead of treating the issue, Trust A just referred her to pain management services and suggested the pain was in her head.
22. Mrs A had an MRI of her cervical spine (neck) in January 2019. A neurologist from another Trust (not part of this complaint) referred her to Trust A for further management. The referral said Mrs A reported pain in her neck and the upper and middle part of her back. The referral noted Mrs A’s recent MRI scan showed some abnormalities, mainly at the discs in her neck, as mild to moderate stenosis.
23. Trust A say Mrs A’s referral was reviewed by the consultant team and discussed by the Spinal Multidisciplinary team (MDT). It says, following review of the referral information and direct review of the scan images, the MDT felt that there was unlikely to be a reasonable target for operative treatment. It decided the most appropriate onward referral was to the ‘non-surgical Spinal Intervention Clinic’ run by the musculoskeletal service, in the first instance.
24. Our adviser says Trust A’s decision that Mrs A was not a surgical target in January 2019 was appropriate and in line with relevant guidance.
25. There are no specific NICE guidelines for chronic neck pain. NICE do have procedure information for cervical (neck) disc replacement. This guidance shows the indication for surgery in this area is irritation of the nerve. Spinal surgery is performed primarily for compressive conditions where there is irritation of the nerves resulting in neurological symptoms.
26. Mrs A’s MRI scan showed no central compression of the spinal cord and showed no compression of the nerves. While one of the benefits of surgery may be a reduction in pain in the cervical spine, this is not guaranteed. There are often multiple sources of pain in the neck, and surgery at a single level will not help all of these.
27. Given Mrs A was not considered a suitable candidate for surgery, our clinical adviser says Trust A’s decision to refer Mrs A to pain management was correct, based on her MRI scans at that time.
28. This is in line with GMC Good Medical Practice Guidance which says, ‘You must provide a good standard of practice and care. If you assess, diagnose, or treat patients, you must refer a patient to another practitioner when this serves the patient’s needs.
29. We recognise this has been a distressing time for Mrs A dealing with her ongoing conditions. We cannot see anything went wrong with how Trust A made its decision about Mrs A’s suitability for surgery or its decision to refer her to another service. Given this, we do not consider there are any indications of maladministration (fault).
Physiotherapy
30. Mrs A attended a physiotherapy appointment at Trust A in January 2020. She says she was under the impression she was being referred for specific rheumatology physiotherapy. She says the physiotherapist said they could not do much for her because she has herniated discs.
31. Trust A say the physiotherapist was trying to assess with Mrs A why she continued to experience neck pain beyond the normal time frame. It says the physiotherapist got the impression Mrs A felt any type of therapy involving movement may worsen her pain. Trust A apologise that Mrs A was given the impression physiotherapy would not be helpful in better managing her persistent pain.
32. The notes from the physiotherapy assessment say Mrs A was ‘very keen to pursue surgical options and does not feel that any other course of action will be satisfactory to relieve her symptoms’. The physiotherapist noted Mrs A did not wish to engage in the assessment and they were ‘unable to reassure her physiotherapy could be of benefit to her’.
33. Our adviser says the role of physiotherapy is to improve the function of muscles and range of motion in the neck. Physiotherapy would not influence the natural history of any disc herniation (bulged, slipped, or ruptured disc) and would not be able to change this.
34. From the notes it appears Mrs A was reluctant to engage with the physiotherapist. Although we do not doubt Mrs A’s recollection, it appears there was a misunderstanding about whether physiotherapy could help her. The notes suggest the physiotherapist did offer to assess Mrs A, but she declined. Given this, we cannot see there are any indications of maladministration in respect of this part of Mrs A’s complaint.
Trust B
Surgical Intervention
35. Mrs A says she believes her pain is structural and she needs surgery to help alleviate her symptoms.
36. Mrs A had a private MRI scan in October 2019. This showed ‘mild degenerative changes in the coccyx, the bony structure at the bottom of the spine, and stress reaction in right base of the lumbar spine with possible displaced fracture’. A displaced fracture is where the ends of the bone have come out of alignment.
37. Mrs A was referred back to the MSK service in November 2019. She attended a clinic appointment in January 2020 and clinicians arranged an MRI scan.
38. The MRI of Mrs A’s cervical and thoracic spine in February 2020 showed there was some disc protrusion in her upper back and an asymmetrical bulge contacting the exiting left C7 disc nerve root. The report says all other imaged discs appear normal.
39. The spinal MDT decided there was no indication for surgical intervention.
40. The Trust say persistent pain is a diagnosis and it is very complex. It says persistent pain is a long-term condition where the body continues to send pain signals to the brain long after the initial problem has settled.
41. Our adviser says the MRI scan of Mrs A’s pelvis from October 2020 does show a healing fracture at the base of the lumbar spine, probably due to her osteoporosis, a condition that weakens bones, but this would not require surgical intervention. As above, there are no specific guidelines in this area.
42. Mrs A’s MRI scan of her cervical and thoracic spine, performed in February 2020, does not show any significant difference. There is reference to possible irritation of the left C7 nerve on the cervical spine. Our adviser says there does not appear to be any correlation between the scan findings and Mrs A’s description of her symptoms. This would mean surgery would be unlikely to be successful.
43. Given this, we are not critical of Trust B’s decision not to offer Mrs A surgery in February 2020, and we can see no indications of maladministration.
MRI scan
44. Mrs A says she believes she needed a scan in May 2019, but Trust B said she did not meet the criteria for an MRI scan.
45. Mrs A had an appointment with the MSK service on 9 May 2019. The notes show Mrs A discussed her three-year history of coccyx pain. She reported it was worsening and that she struggled to sit. Mrs A asked for a scan as she felt there was a structural issue, and something was being missed.
46. The notes show the clinician spoke with a senior staff member who felt there was no indication for lumbar imaging as she was ‘neurologically intact and nil trauma’. They then communicated this decision to Mrs A.
47. Coccydynia (coccyx pain) has several causes. A recent clinical study (Finsen et al) found over 90% of cases will settle with conservative treatment. A further clinical study (Skalski et al) found that imaging is inconclusive in most cases. No national clinical guidelines exist in this area and would be devolved to local guidelines.
48. Trust B apologise that the clinician who spoke with Mrs A did not make it clear to her why she was not suitable for an MRI scan. It says, in line with the Royal College of Radiology Guidelines, an MRI scan would be indicated if a patient displays or describes episodes of neurological deficit, or if there has been trauma. This was not the case with Mrs A.
49. Our adviser says MRI scans do not influence the outcome of coccydynia. This has been found in a study of surgical patients where surgery was unsuccessful in 25% of patients with normal imaging, and 32% with abnormal imaging (Moushine et al).
50. We cannot see there was an indication for an MRI scan in May 2019. As set out above, Mrs A later had MRI scans in October and February 2020. Based on the findings of these scans, clinicians decided Mrs A was not a suitable candidate for surgery. We are not critical of this decision. We do not consider an MRI in May 2019 would have made any difference to the eventual outcome and her overall management, given later scans did not lead to any different decision. We therefore cannot see any indications there is a linked injustice to this claimed failing and we will take no further action.