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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)
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 headachesor 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
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 L
Elbow 2+ 2+
Brachioradialis 2+ 2+
Patellar 3+ 0
Ankles 0 0
Positive Babinski sign bilaterally
Sensory: Intact to light touch in feet bilaterally
Gait: Unable to attempt due to pain
Labs:
2
Chemistry Blood:
11-02-2009 13:30
Glucose, Blood 117 Albumin, Blood 3.5
Urea Nitrogen, Blood 12 Immunofixation Electrophoresis, Blood PEND
Creatinine, Blood 1.0 Lactate Dehydrogenase 295
eGFR (MDRD), Blood >60 Hemoglobin A1c 6.5
CO2, Total (Bicarbonate) 25.8 PSA Screen, Blood 2.9
Chloride, Blood 97 CRP 20.3 [0.1-4.9]
Sodium, Blood 132 ESR 65
Potassium, Blood 3.8
Calcium, Blood 8.9 Hematology Urine:
Opacity, Spot Urine Clear
Hematology Blood: Color, Spot Urine Yellow
White Count, Blood 6.9 Specific Gravity, Spot Urine 1.022
Hemoglobin, Blood 13.8 pH, Spot Urine 7.5
Hematocrit, Blood 43.4 Glucose, Spot Urine Negative
MCV, Blood 92 Ketones, Spot Urine Small
RDW, Blood 14.5 Blood, Spot Urine Small
Platelet Count, Blood 156 Leukocyte Esterase Negative
.% Neutrophils, Blood 74 Nitrite, Spot Urine Negative
.% Lymphocytes, Blood 14 WBC/HPF, Spot Urine 0-1
.% Monocytes, Blood 11 RBC/HPF, Spot Urine 2-5
.%Eosinophils, Blood < 1 Bacteria, Spot Urine FEW
ANC, Blood 5.1 Mucus, Spot Urine FEW
Hyaline Casts, Spot Urine 1
Protein Total, Blood 9.4
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 haptoglobin-hemoglobin 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 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 creatinine1.
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.