A FFPMRCA station on MedMock, start to finish

Good morning. You have had ten minutes to review the referral packet for Mr Vance. Please start by giving us your biopsychosocial formulation of his presentation.

Mr Vance is a 44-year-old delivery driver presenting 16 months after an L4/5 microdiscectomy with persistent post-surgical spine syndrome, predominantly right L5 neuropathic radicular pain with a secondary axial nociceptive and nociplastic component. Biologically, he has burning L5 dermatomal pain and brush allodynia with post-operative perineural fibrosis on gadolinium MRI rather than recurrent compressive disc prolapse, compounded by ineffective high-dose opioid and gabapentinoid polypharmacy causing sedation. Psychologically, his PHQ-9 of 16 and Pain Catastrophising Scale of 36 indicate moderately severe depressive symptoms, high catastrophising, fear-avoidance beliefs around spinal re-injury and severe sleep disruption. Socially and occupationally, he has been off work from heavy manual driving and lifting for nine months, creating financial and role loss that reinforces disability.

What red flags and examination priorities would you confirm in clinic before finalising your diagnosis?

First, I would screen systematically for cauda equina syndrome and progressive neurological deficit: new or bilateral radicular pain, saddle anaesthesia, bladder hesitancy, urinary retention or overflow incontinence, faecal incontinence and gait disturbance. Second, I would screen for post-operative spinal infection or occult malignancy: fever, night sweats, unexplained weight loss and thoracic pain. On examination, I would document a baseline lower-limb neurological chart to compare against his pre- and post-operative notes—specifically right L5 extensor hallucis longus and ankle dorsiflexion power, L4/L5/S1 dermatomal pinprick and light-touch sensation, dynamic mechanical allodynia and hyperalgesia in the L5 territory, knee and ankle reflexes, plantar responses, dural tension signs and lumbar movement patterns including fear-guarded movement.

His gadolinium MRI shows perineural scar around the right L5 root with no recurrent disc herniation. How would you approach his current analgesic regimen?

His current regimen combines high-dose modified-release and immediate-release morphine with pregabalin, yet his BPI interference remains 8 out of 10 and he has daytime sedation. In line with the Faculty of Pain Medicine Opioids Aware guidance, escalating or maintaining high-dose opioids in chronic non-cancer radicular pain carries substantial risks—sedation, cognitive impairment, hypogonadism, hyperalgesia and driving impairment under Section 5A of the Road Traffic Act 1988—without evidence of sustained functional benefit. I would explain this openly and agree a collaborative, slow, structured opioid taper, starting by eliminating the immediate-release morphine and then reducing the modified-release preparation in small steps every two to four weeks with regular review. Once the opioid reduction is underway, I would also review whether pregabalin is providing meaningful neuropathic relief or mainly additive sedation, and consider a trial switch to duloxetine, which addresses both neuropathic pain and his comorbid depressive symptoms.

What role, if any, do interventional procedures or neuromodulation have in this man, and how does that fit into your multidisciplinary plan?

Re-operation is not indicated because there is no recurrent compressive lesion on gadolinium MRI. Repeat epidural steroid injections have limited durability in established post-surgical fibrosis, though a targeted transforaminal epidural with non-particulate dexamethasone under fluoroscopy can occasionally provide a short window for rehabilitation. For refractory unilateral neuropathic radicular pain after spinal surgery, NICE TA159 supports spinal cord stimulation as an option, provided he first undergoes multidisciplinary assessment and a successful screening trial. Before any neuromodulation trial, however, the priority is a combined physical and psychological pain management programme—addressing his high catastrophising, fear-avoidance, sleep hygiene and graded functional restoration—alongside vocational rehabilitation toward modified duties and clear statutory fitness-to-drive advice while he remains on sedating medicines.

Thank you. That concludes the Long Case.