P031: LOW BACK PAIN AND LOWER EXTREMITY SYMPTOMS ARE NOT ALWAYS LUMBAR RADICULOPATHY
Katarina Nikolic, MD, Heather Barkin, MD, Danielle Horn, MD, Pham Phung, MD; Jackson Memorial Hospital/UM
INTRODUCTION: Low back pain (LBP) is experienced in 60-80% of adults at some point in their lifetime. The specific anatomic cause of back pain is often impossible to define and only a small percentage of patients have an identifiable underlying cause. However, due to atypical presentation the serious condition such as infection, malignancy, fracture or neurologic disease can be undiagnosed.
The purpose of this presentation is to describe the clinical courses of two patients referred to Pain Clinic for the treatment of mechanical LBP who subsequently developed avulsion fracture of pubic symphysis and neurological symptoms.
CASE 1 PRESENTATION: The first patient is a 69-year-old male with past medical history of malignant melanoma, who was referred to Pain Clinic for the evaluation and treatment of an insidious onset of persistent LBP associated with left lower extremity weakness of 6 months duration.
The patient attended physical therapy (PT) with limited improvement. He denied any history of trauma and only took acetaminophen with marginal pain relief. He had an unremarkable electromyography study and no evidence of nerve compression on magnetic resonance imaging (MRI).
In our clinic, after a detailed physical exam we found a positive Babinski sign on the left leg and slight hyperreflexia. We referred the patient to a neurologist with the suspicion that his LBP could be cortical in orgin. MRI brain showed 3.5 cm meningioma.
CASE 2 PRESENTATION: The second patient is a 71-year-old male with history of benign spinal tumor s/p resection, cervical/lumbosacral laminectomy for spinal stenosis and osteomyelitis of the pubic symphysis who presented with new LBP, associated with pain radiating down the right leg. The patient was evaluated by an orthopedic surgeon who recommended PT. The patient‘s history and physical examination were consistent with mechanical neuromusculoskeletal dysfunction and no concerning findings were present that warranted immediate medical referral.
We decided to repeat the MRI which showed erosive changes secondary to the osteomyelitis. The patient developed an avulsion fracture of the pubic symphysis.
CONCLUSION: These two cases are examples of how vigilant clinicians have to be while investigating the cause of worsening LBP.
In patients with a history of chronic back pain, close attention should be paid to signs that can suggest a pathologic condition.