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Case Write-up #6: Low back pain
Chief Complaint: 81 year old man with history of multiple myeloma admitted w severe low back pain.
History of Present Illness: RS is an 81 year old male with a past medical history of Multiple Myeloma, Normal Pressure
Hydrocephalus status post ventriculoperitoneal shunt, Type-2 Diabetes mellitus, and Nephrolithiasis who presents with a 3
day history of progressively worsening low back pain.
He was in his usual state of health until 3 days prior to admission, when he began experiencing pain in his left lower back.
The pain started at night and was not associated with any inciting activity, so he assumed it was due to the cold rainy
weather and paid no attention. The pain was initially mild and crampy, but got progressively worse until the morning of
admission when he experienced a sudden back pain shooting down his legs while getting out of the bathroom. The sudden
pain made him dizzy and nauseous, and caused him to lose his balance and fall on his buttocks. He reports no injury to the
head or loss of consciousness and has experienced increased pain since the fall. His home aid, who visits twice a week, came
by and called an ambulance.
He describes the pain as a 4/10 at rest with exacerbation to "20 out of 10" when he moves or rolls in bed. It does not radiate
down his legs or up his back. Before the fall, the pain was relieved by Percocet and got better on lying down and worse on
sitting, standing or acutely when he coughs. After the fall, the pain is aggravated by any movement of his back or upper
legs. He reports a history of unsteady gait since 2005, which has caused him to fall occasionally. His last fall before this
incident was 3-4 weeks ago. He also reports a several-year history of burning sensation with numbness & tingling on the
heels of both feet at night. He reports a 2 day history of nausea and decreased appetite, but no headaches, weakness or
paralysis in his legs; no bowel or urinary incontinence, pain or difficulty urinating. He denies experiencing any trauma acutely
before the initial onset of the pain, and denies fever or chills.
At the ED, his vitals were T 97.6, HR 76, BP 165/72, RR 19 and SpO2 97% RA. He was given IV morphine for pain and a CT
scan of his abdomen and pelvis revealed an expansile lytic lesion of the L4 pedicle.
Past Medical History:
Multiple Myeloma (~2003)
Normal Pressure Hydrocephalus status post ventriculoperitoneal shunt (~2005)
Neuropathy, Ataxia
Coronary artery disease status post 4-vessel coronary artery bypass graft (~1998)
Congestive Heart Failure
Non-Insulin Dependent Diabetes Mellitus (glucose normally in 114-140 range)
Hypertension
Hyperlipidemia
Nephrolithiasis
Vitamin B12 deficiency
Enlarged prostate
Past Surgical History:
4-vessel Coronary Artery Bypass Graft (1998)
Kidney surgery for renal calculi
Eye surgery bilaterally (Oct 2009)
1
Family History:
Father, died in his 70s: Parkinson's disease
Mother, died in her 80s: HTN, heart disease
Brother, 75 years: colorectal cancer
Sister, 69: no known conditions
2 children: no known conditions
Social History:
He is currently retired, but previously worked in construction, as an iron worker and an engineer at the Yale power plant. He
lives at home with his wife in Mount Carmel, Hamden and no pets. He ambulates with a walker, needs assistance with
activities of daily living and was receiving home care services prior to admission, including monthly visits from a skilled nurse
and visits twice a week from a home health aide from the New England Home Health Care. He quit smoking 20 years ago
and reports no alcohol or recreational drug use.
Medications:
Glyburide 2.5 mg oral tablet: 1 tab(s) orally once a day
Aspirin 81 mg oral tablet: 1 tab(s) orally once a day
Lisinopril 40 mg oral tablet: 1 tab(s) orally once a day
Lipitor 40 mg oral tablet: 1 tab(s) orally once a day
Aricept 10 mg oral tablet: 1 tab(s) orally once a day (at bedtime)
Lexapro 5 mg oral tablet: 1 tab(s) orally once a day
Vitabee 12 injectable solution: 1 dose injectable once a month
Aciphex 20 mg oral enteric coated tablet: 1 tab(s) orally once a day
Coenzyme Q10 200 mg oral capsule: 1 tab(s) orally once a day
Allergies:
Sulfonamides: Rash (Minor)
Review of Systems:
General Symptoms: Denies chills, fatigue, fever and weight loss.
Neurological Symptoms: Reports dizziness; denies headaches or syncope.
Eye Symptoms: Reports discharge and itch/irritation/inflammation; had recent eye surgery.
Ear Symptoms: Denies pain and discharge.
Nose/Mouth/Throat Symptoms: Denies nasal obstruction and sore throat.
Cardiovascular Symptoms: Denies chest pains, palpitations, edema, palpitations and PND.
Gastrointestinal Symptoms: Reports nausea; denies abdominal pain, BRBPR, diarrhea, dysphagia, hematemesis and melena.
Genitourinary Symptoms: Denies discharge, dysuria, hematuria, incontinence and nocturia.
Musculoskeletal Symptoms: Reports back pain and stiffness; denies joint swelling.
Skin Symptoms: Denies rash.
Immunological/Endocrine Symptoms: Denies cold intolerance, heat intolerance, polyuria/polydipsia and urticaria.
Psychiatric Symptoms: Reports anxiety from pain.
Physical Exam:
Vital Signs: Temperature 98.4, Heart Rate 75, Blood Pressure 196/83, Respiration Rate 19, SpO2 94% on room air
Pain: 4/10
General Appearance: Lying in bed, in acute distress due to pain
HEENT: Normocephalic, atraumatic; pupils equal round and reactive to light and accommodation, extraocular movement
intact, mild erythema of left lower eyelid with clear discharge; pale oral mucosa with halitosis, no erythema or exudate.
Neck: normal range of motion, no lymphadenopathy
Chest: Clear to auscultation bilaterally
Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops
2
Abdomen: Soft but mildly tensed up, non-distended, non-tender, no hepatosplenomegaly or mass appreciated
Rectal: Rectal hemorrhoids, no bleed, normal tone
Back: Diffuse tenderness to palpation of left flank
Skin: Scaly dry skin
Neurological: Alert and Oriented x3, Folstein 25/30 (Spelled D-L-O-R-W, could only remember 2/3 short-recall words, poor
design copying and sentence writing)
CN II-VII intact bilaterally
Positive straight leg raise in both legs, right>left
Motor:
R
L
Finger abduction
5/5
5/5
Wrist extension
5/5
5/5
Elbow extension
5/5
5/5
Elbow flexion
5/5
5/5
Shoulder abduction
5/5
5/5
Great toe extension
4/5
5/5
Ankle dorsiflexion
4/5
5/5
Ankle plantar flexion
5/5
5/5
Hip abduction
4/5
5/5
Hip extension
4/5
5/5
Motor testing of lower extremities was limited due to pain
Reflexes:
R
Elbow
2+
Brachioradialis
2+
Patellar
3+
Ankles
0
Positive Babinski sign bilaterally
Sensory: Intact to light touch in feet bilaterally
Gait: Unable to attempt due to pain
L
2+
2+
0
0
Labs:
Chemistry Blood:
11-02-2009 13:30
Glucose, Blood
Urea Nitrogen, Blood
Creatinine, Blood
eGFR (MDRD), Blood
CO2, Total (Bicarbonate)
Chloride, Blood
Sodium, Blood
Potassium, Blood
Calcium, Blood
117
12
1.0
>60
25.8
97
132
3.8
8.9
Hematology Blood:
White Count, Blood
Hemoglobin, Blood
Hematocrit, Blood
MCV, Blood
RDW, Blood
Platelet Count, Blood
.% Neutrophils, Blood
.% Lymphocytes, Blood
.% Monocytes, Blood
.%Eosinophils, Blood
ANC, Blood
6.9
13.8
43.4
92
14.5
156
74
14
11
<1
5.1
Protein Total, Blood
9.4
Albumin, Blood
3.5
Immunofixation Electrophoresis, Blood PEND
Lactate Dehydrogenase
295
Hemoglobin A1c
6.5
PSA Screen, Blood
2.9
CRP
20.3 [0.1-4.9]
ESR
65
Hematology Urine:
Opacity, Spot Urine
Color, Spot Urine
Specific Gravity, Spot Urine
pH, Spot Urine
Glucose, Spot Urine
Ketones, Spot Urine
Blood, Spot Urine
Leukocyte Esterase
Nitrite, Spot Urine
WBC/HPF, Spot Urine
RBC/HPF, Spot Urine
Bacteria, Spot Urine
Mucus, Spot Urine
Clear
Yellow
1.022
7.5
Negative
Small
Small
Negative
Negative
0-1
2-5
FEW
FEW
Hyaline Casts, Spot Urine
1
3
CT Abdomen & Pelvis:
1. No evidence of obstructing calculus in the bilateral ureteral collecting system.
2.
Expansile lytic lesion of the L4 pedicle which may represent metastatic disease versus myeloma.
Further workup to rule out metastatic disease is recommended.
Read by: Gunabushanam, Gowthaman.
MRI:
Multiple new foci of abnormal enhancement in the thoracic spine, lumbar spine, sacrum, and iliac bones most likely
representing myeloma lesions. The largest lesions are seen in the T10 and L4 vertebral bodies. The L4 lesion demonstrates
epidural extension of tumor, which causes mild spinal canal narrowing. Multilevel degenerative changes as described, most
pronounced at C3-4 where there is severe spinal canal narrowing and at the L3-4 level where there is moderate spinal canal
narrowing.
No acute signal abnormality is seen in the spinal cord.
Left lower lobe pulmonary consolidation and possible right lower lobe pulmonary nodule for which further evaluation with
chest CT is advised if not already performed.
Serum Protein Electrophoresis
Albumin
3.74 [3.5-4.7]
Alpha 1
0.29 [0.1-0.4]
Alpha 2
0.82 [0.5-0.8]
Beta
1.23 [0.5-1.1]
Gamma
3.32 [0.7-1.5]
INTERPRETATION: Discrete abnormal band measuring 3.15 g/dL present in the gamma region with marked suppression of
the background polyclonal gamma globulins. On 04/29/2008 this band was too weak to quantify but note was made of a
history of monoclonal IgG kappa last detected on 10/23/2006. Recommend correlation with pending immunofixation
electrophoresis (IFE).
Specimen is hemolyzed. Discrete band present between alpha-2 and beta globulins most likely represents haptoglobinhemoglobin complex and may be the cause of a falsely elevated level of beta globulin. Cannot definitively rule out underlying
monoclonal component. Mild increase in alpha-2 globulins.
Signed at 11/04/2009 05:52 by John Hugh McClaskey (MCCLJH7C0E)
Metastatic Series:
1.
Ill-defined lytic lesion located on either side of the left sacroiliac joint, as described above, is likely compatible with
patient's history of multiple myeloma. There has been no significant interval change when compared to the prior
examination, when allowing for differences in technique.
2. Interval progression of T12, L1, and L2 compression fractures.
Read by: KATZ, LEE.D
Chest X-Ray:
There is linear consolidation of the left lower lobe representing subsegmental atelectasis. The right lung is clear. No pleural
effusions or edema. No change from previous study. Pleural thickening is unchanged from prior examination.
Read by: TOCINO, IRENA
Assessment and Plan:
RS is an 81 year old male with a past medical history of Multiple Myeloma, Normal Pressure Hydrocephalus status post
ventriculoperitoneal shunt, Coronary artery disease status post 4-vessel coronary artery bypass graft, Type-2 Diabetes
mellitus, Neuropathy, Ataxia and Nephrolithiasis who presents with a 3 day history of progressively worsening low back pain
with CT pelvis showing a lytic L4 lesion, that is being worked up for possible recurrence of his myeloma.
RS’s presentation of acute progressively worsening low back pain with signs of focal neurologic deficits (weakness on his
right side of the great toe extensor, hip extensor and abductor), upper motor neuron lesions (hyperreflexia in the right
patellar, positive Babinski sign bilaterally), elevated total protein of 9.4 and a lytic L4 pedicle lesion on the CT pelvis together
point to neurologic injury due to an underlying disease. Given his history of Multiple Myeloma, recurrence remains the
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primary concern as the cause of the pain. However the differential for his presentation in broad classifications can also
include: Mechanical causes (including Lumbar strain, Degenerative disc disease, Spinal stenosis, Disc herniation, Cauda
equina syndrome, Compression fracture), referred causes (such as pyelonephritis, nephrolithiasis), or systemic causes (other
malignancies).
Multiple Myeloma is a neoplasm characterized by clonal proliferation of a terminally differentiated plasma cell in the bone
marrow, resulting in extensive skeletal destruction with osteopenia, lytic lesions and fractures, as well as renal failure,
anemia, and hypercalcemia. The initial symptoms include bone pain, fatigue, weight loss, recurrent infections, neuropathy,
with associated signs such as hypercalcemia and elevated creatinine 1.
A constant progressively worsening bone pain in the back or chest is observed in ~60% of patients at time of diagnosis and
up to 80% through the course of disease1. It is produced by infiltration of the plasma cells in the bone which cause lytic
lesions that can lead to bone collapse (such as vertebral collapse causing loss of height). It can also cause paravertebral or
extramedullary plasmacytomas that can compress the spinal cord or nerve roots. Cord compression occurs in ~5% of cases,
and is typically suspected in patients who present with severe back pain, lower extremity paresthesia or weakness, or
bowel/bladder dysfunction1.
RS, already diagnosed with Multiple myeloma, presented with similar symptoms of pain as described above, with paresthesia
and right-sided lower extremity weakness. An MRI of his spine showed that the expansile lytic L4 lesion initially identified on
the CT had an epidural extension causing mild spinal canal narrowing questionable for compression of the spinal cord or a
nerve root. Additionally, several smaller lesions were seen on several levels throughout the lumbar spine and portions of the
sacrum and iliac bones suggestive of neurologic damage due to neoplastic infiltration of the spine. RS’s neurologic findings
are characteristic of both upper and lower motor neuron lesions which could be explained by the numerous infiltrative spinal
lesions. For instance the right patellar hyperreflexia (L2-4) and positive bilateral Babinski reflexes (L5-S2) indicate upper
motor neuron lesions from damage to the corticospinal tract probably in the lumbar region,(one can’t damage the
corticospinal tract in the lumbar region, as the cord ends around L1) but possibly anywhere in the spinal cord or brain. The
left patellar areflexia (L2-4) indicates lower motor neuron injury, which could be anywhere distal to the anterior horn,
including the nerve root. The motor weakness observed in his right great toe extensor (L5), hip extensor (L5-S1) and hip
abductor (L4-5) point to both upper and lower motor neuron lesions as possible causes (the weakness is probably lower
motor in origin, although the upgoiong toes give concern for an upper motor lesion).
Although he was already diagnosed and treated for Multiple myeloma, RS’s serum protein electrophoresis showed a new
monoclonal spike in the gamma region, suggestive of a recurrence of his myeloma. This fits with the presentation of the new
bone lesions as the most likely cause of his acute low back pain.
MECHANICAL PAIN
Mechanical pain refers to anatomical or functional causes of pain without underlying malignancy or inflammatory disease.
Low back pain is the second most common reason for physician visits in the US, affecting about 67% of adults, and
mechanical causes account for 97% of them2.
Lumbar strain accounts for up to 70% of cases of mechanical back pain and typically presents as a sharp intense pain with
muscle spasm over 1-2 days, with stiffness or soreness that resolves within 3 months. It is usually, but not always associated
with traumatic onset2. Exam is usually benign with no abnormalities seen on imaging, which is not the case for RS. Lumbar
strain is usually a diagnosis of exclusion (after all testing has come back negative) and is not considered as a likely cause of
RS’s pain.
Degenerative disk disease accounts for 10% of cases of mechanical back pain and is associated with spinal changes such
as herniation (4%), compression fractures (4%) and stenosis (3%). Disc degeneration is a normal process of aging and does
not cause symptoms in most people, but can cause severe constant chronic pain in others. The pain is exacerbated by
coughing as in RS’s case and by heavy lifting. Typical exam findings include mild back tenderness and decreased range of
motion with reproducible pain on flexion (suggesting discogenic defects) or extension (suggesting facet arthropathy) 2,3.
Spinal stenosis refers to narrowing of the spinal canal, nerve root canal (radiculopathy) or intervertebral foramina, due to
bony hypertrophy of the facet joints or thickening of the ligamentum flavum. It may present with intermittent pain &
paresthesia radiating to the thighs, calves or legs with worsening on prolonged standing or walking and relief from sitting or
lying down (neurogenic claudication). Symptoms of canal narrowing are commonly bilateral and asymmetrical and typically
involve the entire leg, rather than the upper or lower leg. A radiculopathy may cause pain or paresthesia in the
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corresponding dermatomes of the nerve root, or weakness in the set of muscles it innervates 4. (Spinal stenosis usually does
not cause rest pain, or pain on rolling over – the pain is usually present only with stranding and walking)
Herniation of the nucleus pulposus can also cause radiculopathy, with 98 % occurring at L4-5 and L5-S1. It has a high
association with a positive straight leg raise, which was seen in RS. L5 involvement causes weakness of ankle and great toe
dorsiflexion, and S1 involvement may cause weakness of plantar flexion. While no plantar flexion weakness was observed,
great toe and ankle dorsiflexion were asymmetrically weak on RS’s right side (hernaition of the nucleus pulposis is rare after
the age of 55, as the nucleu drys up and is no longer gel-like after that age).
Cauda equina syndrome is an uncommon complication of lumbar spinal stenosis and herniation (more common with
tumors or trauma), and is associated with defects in multiple roots (L3-S1), bilateral weakness, saddle anesthesia, and
bowel, bladder or erectile dysfunction3.
With these characteristics outlined, we can evaluate their likelihood in RS’s case. RS’s back pain is constant and severe,
worsened by rolling over, sitting or standing, and ameliorated by lying still. His back is tender to palpation and the positive
straight leg raise bilaterally may point to radiculopathy. The back pain, however, does not radiate to his thighs or legs. On his
MRI, there is multilevel degenerative disease with considerable spinal canal narrowing and joint arthropathy at the C3-4 and
L3-4 vertebrae, as well as diffuse disc bulging at L3-4. These correlate very weakly with the neurologic findings of patellar
hyperreflexia (implicating L2-4 nerves) and motor deficits in his right great toe extensor (L5), hip extensor (L5-S1) and hip
abductor (L4-5). Compression fractures such as those seen from vertebrae T12 to L2 on RS’s MRI could also cause pain and
are often associated with a history of trauma, pain at night and at rest, normal neurologic exam and tenderness on midline
palpation3. These fractures were, however, noted to be unchanged from RS’s MRI in 2006.
The imaging evidence for mechanical pain is not strong. But it is not unusual to have a mechanical source of pain without an
identifiable lesion on imaging. That said, the significant evidence pointing to myeloma recurrence is considerably stronger,
making it a more likely cause.
REFERRED PAIN
Acute Pyelonephritis could present with referred severe pain to the flank over a short time-course. However, the typical
presentation also includes acute-onset fever, chills, nausea and vomiting and costovertebral angle tenderness. There may
also be changes in urinary habits, dysuria, frequency or urgency associated with cystitis or urethritis. CBC would typically
indicate leukocytosis and urinalysis would also show a WBC count > 10/HPF, and RBC count > 5/HPF (sensitivity of 72-95%).
RS did not present with a fever or leukocytosis, and given the high sensitivity of the urinalysis, his negative result makes
acute pyelonephritis less likely. (This condition should not give positional pain.)
Nephrolithiasis is also a possible cause of referred flank pain and especially likely for RS given his age and recent history.
More than 50% of patients with renal stones tend to have recurrences. Other symptoms include nausea, vomiting,
hematuria, urinary frequency/urgency, groin or testicular pain, costovertebral angle tenderness, fever, tachycardia and
hypotension. RS did not present with any positive urinary symptoms and his urinalysis was negative. In addition, the CT of
his abdomen showed no signs of ureteral obstruction, making renal colic less likely on our differential.
Plan by Issue:
1.
Low back pain:
Presentation of progressively worsening back pain with right-sided hyperreflexia and focal weakness is concerning for
metastasis vs myeloma, or MSK etiology such as cord compression.
IV Morphine for pain
Will do an MRI to look for spinal lesions or masses concerning for malignancy
Labs: serum/urine immunofixation electrophoresis, beta 2-microglobulin
Total blood protein high at 9.4
Consider skeletal survey to look for other lesions
Consult Heme/onc about possible recurrence of myeloma vs metastasis.
2.
Hypertension:
Continue Lisinopril 40mg
3.
Coronary Artery Disease:
Continue Lipitor 40mg
Continue ASA 81mg
6
4.
5.
Diabetes:
DM well controlled between 114-140 per patient
Do daily finger sticks after meals and administer Glyburide 2.5mg on sliding scale.
Dementia:
Aricept 10mg
6.
Depression:
Lexapro 5mg
7.
Nutrition/Prophylaxis/Code Status/Disposition:
Nutrition: Enteral Regular
DVT Prophylaxis: Heparin
GI Prophylaxis: Pantoprazole
Code Status: Full
Disposition: Pending complete work up of back pain
REFERENCES:
1.
2.
3.
4.
Kyle, RA, and Rajkumar, SV. “Multiple Myeloma”, N Engl J Med 2004; 351:1860-73
Deyo, RA and Weinstein, JN. “Low Back Pain”, N Engl J Med Feb 2001; Vol. 344, No. 5
Wheeler, S. “Approach to the diagnosis and evaluation of low back pain in adults”, UpToDate, 2009
Levin, K. “Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis”, UpToDate, 2009
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