Print Friendly, PDF & Email

A 50 year old gentleman presents to his GP with back pain.


History

Presenting complaint

“This morning I was lifting a TV out of my car when I suddenly developed really awful back pain!”

Have you experienced back pain in the past? Was it like this?

 

Use SOCRATES to gain details of the back pain:

  • Site – Where is the back pain?
  • Onset
    • Did it come on suddenly or gradually?
  • Character
    • What kind of pain is this? (sharp / aching / burning)
    • Is it continuous or intermittent?
  • Radiation – Does the pain move anywhere else?
  • Associated symptoms – Are there any other symptoms that seem associated? (e.g. weakness / numbness / saddle anaesthesia / urinary or faecal incontinence? / weight loss? / fevers? / sweats?)
  • Timing – When exactly did it start?
  • Exacerbating / relieving factors – Does anything make it better or worse?
    • Is it worse when you walk, sit down or lay flat?
  • Severity – On a scale of 1-10 how bad is the pain? Has it gotten better or worse?

 

Patient’s response

“It started as soon as I lifted the television this morning and I felt a click as it started.  There is a constant ache and then sharp pain whenever I try to bend.  The pain is in the lower back and it does not shoot down the leg, paracetamol, ibuprofen and a heat pack have helped a little bit..  I’ve had the ‘usual’ joint aches here and there but nothing this bad ever. I don’t have any weakness or numbness and I’ve opened my bowels today without any issues, I’m also passing water fine. I haven’t noticed any weight loss, fevers or sweats. The pain is definitely worse when I bend, paracetamol and lying still seems to help a little, the pain is about 8/10 at its worst.”

Past medical history:

  • Musculoskeletal conditions – previous fractures / arthritis / osteoporosis
  • Malignancy – any previous or current malignancy?
  • Other medical problems?
  • Allergies?

 

Drug history:

  • Regular medication?
  • Over the counter drugs?
  • Recreational drugs?

 

Social history:

  • Living situation – e.g. house / flat / bungalow 
  • Who does he live with?
  • Level of functional independence
  • Current occupation=
  • Smoking status
  • Alcohol history

 

Travel history:

  • Recent travel? – particularly any areas of high TB prevalence

 

Systemic enquiry:

  • Any other symptoms in other body systems? – weight loss etc

 

Patient’s response

“I have high blood pressure and I’m on Ramipril for that, but otherwise I’m fit and well as far as I know.”

“I live with my wife in a flat and neither of us smokes or drinks. I work as a lorry driver and I’m fully independent.”

“I haven’t travelled anywhere in years and I haven’t noticed any weight loss.”

  • Age <20 or >50
  • Non-mechanical pain
    Thoracic pain
  • Saddle anaesthesia
  • Bladder dysfunction – retention / incontinence
  • Faecal incontinence
  • Limb weakness
  • Associated trauma
  • Weight loss
  • Fever
  • Structural abnormality of spine

Examination

Full spinal examination

Lower limbs neurological examination

 

If there were any history or examination findings suggestive of cauda equina syndrome:

  • Assess perianal sensation
  • Rectal examination – to assess sphincter competence

Gait – the patient is walking slightly ‘stooped’ due to the pain

Palpation – there is tenderness in the lumbar spine

Movement – limited range of movement due to pain

Power –  5/5 bilaterally in both lower limbs

Sensation – normal sensation in all modalities

Reflexes – normal

Rectal examination – not performed


Differential diagnosis

  • Muscular strain
  • Prolapsed disc
  • Vertebral fracture / Osteoporosis
  • Discitis/ Osteomyelitis
  • Rheumatological – rheumatoid/ankylosing spondylitis
  • Spinal stenosis
  • Malignancy – primary bone or metastatic disease

Management

The GP decides to adopt a ‘watch and wait’ approach at this point, given the absence of any neurological signs and short duration of symptoms.

This is questionable, given the gentleman has a number of red flag symptoms.

The management plan is…

1. Sick leave from work for at least 1 week

2. Keep moving – simple exercises given

3. Analgesia – paracetamol, NSAIDs and codeine

4. Reminder that if the situation worsens then to get back in touch

5. Review appointment in two weeks

6. Avoid heavy lifting

Failure to improve

The patient presents two weeks later as planned. The pain is worsening and he has been feeling generally unwell, having spent most of the last week in bed.  His wife is very worried.


Investigations

FBC – neutrophilia in infections / iron deficiency anaemia (malignancy)

U&E – taking NSAIDs + Ramipril – risk of acute kidney injury

LFT – ALP elevation may point towards bone disease (e.g. bony metastases)

Bone profile – hypercalcaemia (e.g. bony metastases)

CRP – signs of infection / inflammation (discitis)

ESR – signs of inflammation (rheumatic conditions)

Imaging – Spinal X-rays (Lumbar/Thoracic) – ?fractures

Investigation results

Hb – 105 g/L (130-170)
WCC – 8.5×109/L (4-11)
Neutrophils – 5.7×109/L (2-7.5)
Lymphocytes – 1.9×109/L (1.5-4)
Platelets  – 190×109/L (150-400)
ESR  – raised

Sodium – 137mmol/L (135-145)
Potassium – 4.9mmol/L (3.5-5)
Creatinine – 150 μmol/L (60-125)
Urea –  8.7 mmol/L (3-6.5)
Calcium (adjusted) –  3.43 mmol/L (2.15-2.5)
Phosphate –  0.8mmol/L (0.7-1.5)
ALP – 250 u/L (60-150)
ALT/GGT – normal
Bilirubin – 12 μmol/L (3-17)
CRP12 (<5)

 

L4 wedge fracture

Lumbar spine XR

Wedge fracture of L4

Hypercalcaemia

  • Primary hyperparathyroidism
  • Malignancy with bone metastases
  • Sarcoidosis
  • Tuberculosis
  • Parathyroid hormone (PTH)
  • Thyroid function tests
  • Serum protein electrophoresis
  • Urine protein electrophoresis (Bence Jones proteins)
  • Measurement of immunoglobulins
  • Vitamin D levels
  • HIV
  • Angiotensin-converting enzyme – sarcoidosis

Not all of these are warranted immediately – e.g. HIV/ACE/Immunoglobulins

Correlate with clinical suspicion.

Even if vitamin D levels are abnormal, one should still rule out more sinister diagnoses.

Intravenous fluids

o.9% sodium chloride can be used to rehydrate the patient and encourage urinary excretion of calcium.

Fluid balance should be monitored closely.

Bisphosphonates

Bisphosphonates reduce bone turnover and can, therefore, be used after patients have been rehydrated (e.g. Pamidronate) 


Further management

He is admitted to hospital.

His ACE inhibitor and NSAIDs are stopped.

His hypercalcaemia is managed appropriately.

Further investigations…

PTH – 0.5 pmol/L (1.05 – 6.83)

IgG –  59 g/L (5.9-15.6)

IgA –  0.5 (0.6-5)

IgM – 0.3 (0.4-2.3)

Serum electrophoresis – band in gamma region

Immunofixation – an IgG Kappa paraprotein is detected totalling 52g/L


Diagnosis

Multiple myeloma

The diagnosis here is likely to be multiple myeloma (a.k.a. plasma cell myeloma).

Plasma cell myeloma is a clonal proliferation of plasma cells.

An initiating event occurs which gives the plasma cell a survival advantage. 

Normal mechanisms to reduce proliferation and induce apoptosis are overcome.

Check out our full guide to multiple myeloma HERE

Features of myeloma

CRAB is a useful mnemonic to help remember the most common features of myeloma:

  • HyperCalcaemia – cytokines result in osteoclast dysregulation
  • Renal failure – light chains clog up the renal tubules
  • Anaemia – the bone marrow becomes overcrowded with plasma cells
  • Bone lesions – cytokines result in osteoclast dysregulation

Definitive diagnosis

A bone marrow aspirate and trephine biopsy looking for a clonal plasma cell proliferation is needed to confirm the diagnosis.

A skeletal survey is also required to stage the disease. 

OLYMPUS DIGITAL CAMERA

Diagnostic criteria

Symptomatic myeloma

Symptomatic myeloma is characterised by the below criteria.

Active treatment is considered for most patients able to tolerate it.

 

The below criteria must be met for a diagnosis of symptomatic myeloma:

  1. Clonal plasma cells >10% on bone marrow biopsy or in a biopsy from other tissues 
  2. A monoclonal protein (paraprotein) in either serum or urine
  3. Evidence of end-organ damage felt related to the plasma cell disorder – e.g. CRAB

 

Asymptomatic myeloma

This type of myeloma is often referred to as “smouldering myeloma”.

It differs from symptomatic myeloma because of the absence of end-organ damage.

It usually doesn’t require active treatment, instead a watch and wait approach is adopted.

 

The below criteria must be met for a diagnosis of asymptomatic (smouldering) myeloma:

  1. Serum paraprotein >30 g/L  
  2. +/- Clonal plasma cells >10% on bone marrow biopsy 
  3. NO myeloma-related organ or tissue impairment

Treatment

This gentleman has symptomatic myeloma, therefore he requires active treatment.

Chemotherapy

Combination chemotherapy is the most common treatment modality.

Radiotherapy is used if there is bony pain or plasmacytoma.

Many patients are enrolled in clinical trials.

 

Autologous stem cell transplant (ASCT)

If patients are young and respond well to chemotherapy, they may be offered an ASCT.

  • First the patient has their stem cells harvested.
  • Then the patient is treated with high dose chemotherapy to wipe out their bone marrow.
  • Once this has occurred, the harvested stem cells are reinfused.
  • This reboots the bone marrow and all cell lines originating from it.
  • Stem cell transplantation does carry a significant risk of death and serious complications, so it is only offered to those patients who are most likely to benefit.

Author

This clinical case scenario was produced by #TEAMHAEM

Check out their site here! or catch them on Twitter @TeamHaem


References

1. Lumbar spinal X-ray – http://en.wikipedia.org/wiki/File:L4_compressionFracture2008.jpg

2. Bone marrow image – http://upload.wikimedia.org/wikipedia/commons/2/21/Multiple_myeloma_%282%29_HE_stain.jpg