Case Write-up #6: Low back pain - Yale School of Medicine



HP SampleStudent Name:_______________________________________________Rotation Dates:_______________________________________________Location Assigned to:_______________________________________________Date Submitted:_______________________________________________REMEMBER, NEVER USE PATIENT’S NAMECase 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, AtaxiaCoronary artery disease status post 4-vessel coronary artery bypass graft (~1998)Congestive Heart FailureNon-Insulin Dependent Diabetes Mellitus (glucose normally in 114-140 range)HypertensionHyperlipidemiaNephrolithiasisVitamin B12 deficiencyEnlarged prostatePast Surgical History:4-vessel Coronary Artery Bypass Graft (1998)Kidney surgery for renal calculiEye surgery bilaterally (Oct 2009) Family History:Father, died in his 70s: Parkinson's diseaseMother, died in her 80s: HTN, heart diseaseBrother, 75 years: colorectal cancerSister, 69: no known conditions2 children: no known conditionsSocial 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 dayAspirin 81 mg oral tablet: 1 tab(s) orally once a dayLisinopril 40 mg oral tablet: 1 tab(s) orally once a dayLipitor 40 mg oral tablet: 1 tab(s) orally once a dayAricept 10 mg oral tablet: 1 tab(s) orally once a day (at bedtime)Lexapro 5 mg oral tablet: 1 tab(s) orally once a dayVitabee 12 injectable solution: 1 dose injectable once a monthAciphex 20 mg oral enteric coated tablet: 1 tab(s) orally once a dayCoenzyme Q10 200 mg oral capsule: 1 tab(s) orally once a dayAllergies: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 airPain: 4/10General Appearance: Lying in bed, in acute distress due to painHEENT: 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 gallopsAbdomen: Soft but mildly tensed up, non-distended, non-tender, no hepatosplenomegaly or mass appreciatedRectal: Rectal hemorrhoids, no bleed, normal toneBack: Diffuse tenderness to palpation of left flank Skin: Scaly dry skinNeurological: 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 bilaterallyPositive straight leg raise in both legs, right>leftMotor:RLFinger abduction5/55/5Wrist extension5/55/5Elbow extension5/55/5Elbow flexion5/55/5Shoulder abduction5/55/5Great toe extension4/55/5Ankle dorsiflexion4/55/5Ankle plantar flexion5/55/5Hip abduction4/55/5Hip extension4/55/5Motor testing of lower extremities was limited due to painReflexes:RLElbow 2+ 2+Brachioradialis2+2+Patellar3+0Ankles 00Positive Babinski sign bilaterallySensory: Intact to light touch in feet bilaterallyGait: Unable to attempt due to painLabs:Chemistry Blood:11-02-2009 13:30Glucose, Blood117Albumin, Blood3.5Urea Nitrogen, Blood12Immunofixation Electrophoresis, Blood PENDCreatinine, Blood1.0Lactate Dehydrogenase295eGFR (MDRD), Blood? ? ? ?>60Hemoglobin A1c6.5CO2, Total (Bicarbonate)? 25.8PSA Screen, Blood2.9Chloride, Blood? ? ? ? 97CRP20.3 [0.1-4.9]Sodium, Blood? ? ? ? 132ESR65Potassium, Blood3.8 Calcium, Blood8.9Hematology Urine:Opacity, Spot UrineClearHematology Blood:Color, Spot UrineYellowWhite Count, Blood6.9Specific Gravity, Spot Urine1.022Hemoglobin, Blood13.8pH, Spot Urine7.5Hematocrit, Blood43.4Glucose, Spot UrineNegativeMCV, Blood92Ketones, Spot UrineSmallRDW, Blood14.5Blood, Spot UrineSmallPlatelet Count, Blood156Leukocyte EsteraseNegative.% Neutrophils, Blood74Nitrite, Spot UrineNegative.% Lymphocytes, Blood14WBC/HPF, Spot Urine0-1.% Monocytes, Blood11RBC/HPF, Spot Urine2-5.%Eosinophils, Blood< 1Bacteria, Spot UrineFEWANC, Blood5.1Mucus, Spot UrineFEWHyaline Casts, Spot Urine1Protein Total, Blood9.4CT 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 ElectrophoresisAlbumin3.74 [3.5-4.7]Alpha 10.29 [0.1-0.4]Alpha 20.82 [0.5-0.8]Beta1.23 [0.5-1.1]Gamma3.32 [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.DChest 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, IRENAAssessment 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 PAINMechanical 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 corresponding dermatomes of the nerve root, or weakness in the set of muscles it innervates4. (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 PAINAcute 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: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 painWill do an MRI to look for spinal lesions or masses concerning for malignancyLabs: serum/urine immunofixation electrophoresis, beta 2-microglobulinTotal blood protein high at 9.4Consider skeletal survey to look for other lesionsConsult Heme/onc about possible recurrence of myeloma vs metastasis.Hypertension:Continue Lisinopril 40mgCoronary Artery Disease:Continue Lipitor 40mgContinue ASA 81mgDiabetes:DM well controlled between 114-140 per patientDo daily finger sticks after meals and administer Glyburide 2.5mg on sliding scale. 5.Dementia:Aricept 10mg6.Depression:Lexapro 5mg7.Nutrition/Prophylaxis/Code Status/Disposition:Nutrition: Enteral RegularDVT Prophylaxis: HeparinGI Prophylaxis: PantoprazoleCode Status: FullDisposition: Pending complete work up of back painREFERENCES:Kyle, RA, and Rajkumar, SV. “Multiple Myeloma”, N Engl J Med 2004; 351:1860-73Deyo, RA and Weinstein, JN. “Low Back Pain”, N Engl J Med Feb 2001; Vol. 344, No. 5Wheeler, S. “Approach to the diagnosis and evaluation of low back pain in adults”, UpToDate, 2009Levin, K. “Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis”, UpToDate, 2009 ................
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