Back Pain - Metastatic Disease

44, male

C/o: 2 month history of central lower back pain.

• Insidious onset
• Worse with lying / night time. Also worse first thing in the morning.
• Wakes up 2-3 times per night due to pain.

Social

• Office Job
• Active Life style
• Enjoys playing sport
• Ex smoker (stopped 12 years ago)
• Weekend drinker

Past medical history of Crohn's disease

• No weight loss
• No night sweats
• No CES signs
• No P+N / Numbness

Paracetamol helps otherwise pain is constant.

Objective

• Full Lumbar spine ROM
• Full Hip ROM
• Normal Neuro exam
• NAD toe standing, single leg standing
• No spinal tenderness on palpation

Impression: Myogenic Low Back Pain

• Advice given on exercises, posture, heat application.

Follow up 4 weeks later (different clinician)

• Reports severe episodes of low back pain, more on right
• Sitting, coughing, sneezing - all painful
• Reflexes - brisk knee jerks
• SLR reduced bilaterally
• No leg pain
• No motor weakness
• ROM - lumbar flexion very limited, Extension eases symptoms slightly

Impression: disc pathology

• Warned about CES and MRI lumbar spine requested.

MRI Lumbar Spine

At L5-S1 there is slight loss of vertebral body height and the marrow signal is diffusely abnormal. There are small foci of abnormal signal intensity within the L4-L3 to L2-T12 and L1 vertebral bodies as well. The discs are normal. The canal is capacious throughout, and the lower cord and conus are normal. There is no lateral recess stenosis or exit foraminal narrowing.

Impression:
The appearances are most suspicious for metastatic disease, or less likely myeloma.