Back Pain

1
Back Pain

• H.S. Sandhu, M.D.
• Division of Emergency Medicine
• Washington University School of Medicine
• Barnes-Jewish Hospital

2
Chief Complaint

• Low back pain
• Abdominal pain

3
History of Present Illness

• 57 yo white, male with history of chronic back
  pain. Now presenting with 3-week history of
  worsening pain
• Sharp, non-radiating
• Worse with movement, no relieving factors
• No leg weakness or loss of sensation
• Pain unrelieved with Lorcet

4
History of Present Illness
Continued--

• Also c/o mid-abdominal cramping x 2-3 weeks
• Non-radiating
• Worse with activity sometimes
• No relieving factors
• No nausea, vomiting, diarrhea
• c/o mild constipation

5
Review of Systems

• Decreased appetite with a 45 pound weight loss in
  2 weeks
• c/o moderate dyspnea on exertion
• Also noted by family to be confused recently
• No cough or hemetesmesis
• No focal weakness or sensory loss

6
Past Medical History

• Polio during childhood without residual deficits
• Hemorrhoids x 10 years
• GERD
• HTN
• L. Bells Palsy - 1 month ago
• Chronic low back pain

7
Allergies

• NKDA

8
Medications

• Lorcet 10/650 PRN back pain
• Skelaxin 400 mg bid
• Norvasc 5 mg po qD
• Avapro 300 mg po qD
• Multivitamin
• Vitamin B

9
Family History

• Great-grandmother had cancer of unknown type
• Brother had prostate cancer

10
Social History

• Smokes 3 ppd for 24 years
• Drinks 6-7 beers a day
• Worked in a factory with chemical exposure for 7
  years

11
Physical Exam

• General appearance In moderate distress due to
  pain
• Temp 36
• HR 94
• Resp 16
• BP 190/104
• Sp02 97 on 21/min by N/C

12
Physical Exam
Continued--

• HEENT Mild L, facial droop, conjunctival pallor,
  otherwise unremarkable
• Neck No JVD, no lymphadenopathy
• Chest Rare, bi-basilar inspiratory rales
• Heart RRR, no murmurs, rubs or gallop
• Abdomen Soft, non-tender, normal active bowel
  sounds

13
Physical Exam
Continued--

• Back Mid-thoracic spine tenderness on palpation
• Skin No icterus, no rashes
• Extremitites No edema, cyanosis or clubbing, 1
  dorsalis pedis pulses B/L
• CNS Mild L. sided facial drop with forehead
  involvement. Otherwise unremarkable

14
Initial Differential Diagnosis

• 57 yo smoker presenting with intractable low back
  pain and weight loss
• Malignancy - lung, GI, bone or hematological
• Infectious - epidural abscess, TB
• Cardiovascular - aortic dissection, AAA
• GI - pancreatitis, gallbladder
• Endocrine - hyperparathyroidism with increased
  bone resorption compression Fx

15
Labs

• CBC
• WBC 6.8 (N 44, L 42, no bands)
• Hb 7.1, Hct 20.2
• Platelets 62

16
Labs
Continued--

• BMP
• Sodium 127
• Potassium 4.1
• Chloride 95
• Bicarb 24
• BUN 52
• Creatinine 3.3
• Glucose 124
• Calcium 14.4

17
Labs
Continued--

• Alk Phos 52
• AST 50
• ALT 43
• Total Protein 16.1
• Albumin 2

18
Labs
Continued--

• Total Bili 0.3
• Direct Bili 0.2
• PTT 27.8
• INR 1.62
• Myoglobin 294
• Troponin 0.1

19
Labs
Continued--

• UA
• 1 blood
• 3 protein
• 2 RBC/hpf
• 10 WBC/hpf
• 1 fine granular cast
• 2 WBC casts

20
12 Lead EKG - Normal
21
Chest X-Ray

• Multiple lytic lesions in both clavicles. Left is
  greater than right
• Changes consistent with hyperinflated lung fields

22
T and L spine X-Rays

• Compression fractures of T6 and 8
• Diffuse osteopenia

23
Revised Differential Diagnosis

• Malignancy
• Multiple Myeloma - Given pts anemia,
  thrombocytopenia, hypercalcemia, ARF, multiple
  compression fractures, hyperprotenemia
• Lung Ca producing PTH related proteins

24
Revised Differential Diagnosis
Continued--

• Endocrine - primary hyperparathyroidism due to
  adenoma, hyperplasia or carcinoma

25
ED Course

• IV fluids - normal saline
• Type and cross matched - pt refused transfusion
• IV Zoledronic acid (Bisphosphonate) 4 mg IV over
  15 minutes
• IV Morphine for analgesia
• Admitted to Internal Medicine for further work-up

26
Hospital Course

• S-PEP IgG lambda monoclonal spike
• Beta2 microglobulin 10.1
• IgM 6.7 g/dl
• IgA 7.3 g/dl

27
Hospital Course
Continued--

• Bone marrow biopsy many plasma cells
• Skeletal survey multiple lytic lesions
• Steroids for lytic lesions
• Pt to follow-up with oncology in his hometown

28
Final Diagnosis

• Multiple myeloma

29
Multiple Myeloma Facts

• A plasma cell malignancy usually of older adults
  (median age 60) causing
• Bone marrow replacement
• Bone destruction
• Paraprotein formation

30
Multiple Myeloma Facts
Continued--

• Bone marrow replacement anemia and
  pancytopenia recurrent infections esp.
  encapsulated organisms eg. Strep. pneumoniae
• Bone destruction bone pain, osteoporosis,
  lytic lesions and pathologic fractures

31
Multiple Myeloma Facts
Continued--

• Osteoclast activating factor or other lyphokines
  hypercalcemia
• Malignant plasma cells or plasmacytomas have a
  predilection to cause spinal cord compression

32
Multiple Myeloma Facts
Continued--

• Paraprotenemia hyperviscosity syndrome
• Light chain component of the immunoglobulin
• Renal failure
• Deposited in various tissues as amyloid

33
Multiple Myeloma Facts
Continued--

• Diagnosis
• SPEP Monoclonal spike in the beta or gamma
  globulin region, but 15 do not have any serum
  paraproteins
• UPEP Complete immunoglobulins or light-chain

34
Multiple Myeloma Facts
Continued--

• Treatment
• Chemo
• SPEP useful marker for monitoring response to
  treatment
• Bone marrow transplant may also be useful
• Bisphosphonates used to treat hypercalcemia

35
Multiple Myeloma Facts
Continued--

• Prognosis - median survival 3 years

36
References

• Kumar A. Management of multiple myeloma A
  systematic review and critical appraisal of
  published studies. Lancet Oncol 2003 May
  4(5)293-304
• Ashcroft AJ. Aetiology of bone disease and the
  role of bisphosphonates in multiple myeloma.
  Lancet Oncol 2003 May4(5)284-92
• Leung N. Long term outcome of renal
  transplantation in light-chain deposition
  disease. Am J Kid Dis 2004 Jan43(1)147-53