Day 85 - "That sounds bad"

Back pain is one of the most frequent complaints in medicine. Today's case highlighted why it always needs to be taken seriously.

Back Pain:

• Mechanical: Classically worsens with movement, better with rest. Can be referred down to bilateral hips, thighs.
  
  • Patterns:
    
    • Radiculopathy (classically sciatica): pain radiates in dermatome of nerve root impingement. May be associated with neurologic symptoms (weakness or numbness) in the affected area
    • Spinal Stenosis: pain radiates to legs. Worse with activity. Predictably improves with leaning forward, rest
      
  • RED FLAGS:
    
    • Night pain
    • B-Symptoms (fever, sweats, weight loss)
    • Neurological symptoms including numbness, weakness, bladder incontinence (overflow), fecal incontinence (loss of sphincter tone)
      
    • Known history of malignancy
      
• Inflammatory: associated with morning stiffness, aggravated by rest, possibly extra-axial symptoms of connective tissue disease.
• Referred pain

The examination should include a general exam looking for signs of systemic disease. A focussed exam should look for focal bony or paraspinal tenderness, and neurological findings (including rectal tone if appropriate), and associated MSK findings.

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In the case today the patient had progressive, severe back pain in the context of 2 months of B-symptoms. He presented with cord compression.

Differential:

• Malignancy:
  
  • Most commonly prostate, breast, lung. Then RCC, lymphoma and myeloma
  • Pain (present in 95%) is often the first symptom, usually preceeding neurologic symptoms by several weeks
  • Weakness (up to 85%) and sensory losses follow. Can also have bowel/bladder dysfunction and gait ataxia.
  • Patients should get steroids (dexamethasone 10mg IV x 1 then 16mg/day in divided doses tapered over 2 weeks), intravenous pamidronate, and either neurosurgery or radiation.
    
  • This trial showed that for metastatic disease in a single area, surgery +RT was superior to RT alone for solid tumors.
• Infection:
  
  • Spinal epidural abscess
  • Vertebral osteomyeltis including Pott's disease.
• Other:
  
  • Traumatic, vertebral compression fracture

Diagnosis is best made with MRI. If MRI is not an option, the next best test would be a CT myelogram.