Chronic or recurring back pain

Chapter 16 Chronic or recurring back pain



Case 16.1



1. Using only this information, list the possible causes of Celine’s pain. Justify your answer.






























Primary differential diagnosis Justification
Disc lesion L5–S1 Distribution of pain, age
Sacroiliac syndrome
• sacroiliitis

• degenerative joint disease
 Localisation of pain with referred pain from piriformis
Spondyloarthrosis resulting in central/subarticular/foraminal stenosis Distribution of pain and character of pain
Secondary differential diagnosis  
L5–S1 facet dysfunction Distribution of pain
Hypothyroidism Depressed, thyroid problems in the past
Depression / stress Issues with her mother
Complications related to hepatitis C Diagnosis of hepatitis C

2. What do you need to examine in this patient?
• Sacroiliac (SI) joints and lumbar spine.

• Abdominal examination.

• Peripheral nervous system exam.

• Neck examination.

3. Describe the functions of the following tests:
a Gaenslen’s test

This test is used to assess for SI joint dysfunction, pubic symphysis instability, hip pathology or a L-4 nerve root lesion. The patient is placed in a supine position, with both their legs drawn onto their chest. Shift the patient to the side of the couch, so that one buttock extends over the edge of the table while the other remains on it. Allow the unsupported leg to drop over the edge, while the opposite leg remains flexed. Pain during this manoeuvre is a positive finding.


b Gillet’s motion palpation test

This test is performed in the standing position, and is used to assess for SI joint dysfunction.


4. What information can you obtain from these findings? Can you narrow your differential diagnosis?
• SI joints are likely to be implicated.

• Lumbar spine examination is normal, therefore her problem is less likely to involve the lumbar spine.

5. Explain the significance of the following signs, in context of your differential diagnoses.
a lumbar range of movement was normal

Low probability of the origin of the pain eminating from the lumbar spine.


b neurologic examination normal in the lower limb

Low probability of the origin of the clinical syndrome involving the lumbar neurologic levels.


c sacroiliac joint tests positive

Despite the validity of the tests being somewhat subjective, the sacroiliac joint region appears to be the site of origin of the patient’s pain.


6. Celine is referred to a medical practitioner. What investigations are required? Why?

Radiographs to assess the sacroiliac joints, initially on AP pelvic view and then, if necessary (following the AP pelvic view), additional views (SI joint views) to evaluate the articular/subchondral line in more detail.


7. What is the most likely diagnosis, based on these results? Justify your answer.

Bilateral osteitis condensans illii and osteitis pubis. In addition there are degenerative changes to both sacroiliac joints and the pubic symphysis.


8. Are any further investigations required?

No. It is not necessary to have further imaging or laboratory investigations.


9. What is the current hypothesis regarding the aetiology of this disorder?

The disorder is believed to be due to the combination of hormonal and secondary mechanical stresses (especially those occurring during pregnancy). It is related more specifically to the anterior sacroiliac ligament/capsule, resulting in increased mechanical forces/stresses being placed on the ilium.


In Celine’s case, her regular cycling is relevant due to the increase in mechanical forces that she is exposed to.


10. Can this pathology be found outside the pelvic region?

Yes. There is a diagnosis called osteitis condensans of the clavicle. It is unrelated to pregnancy but demonstrates similar changes on imaging, and is likely related to local mechanical stress in the sternoclavicular region.



Case 16.2



1. Using only this information, list the possible causes of Bruce’s pain. Justify your answer.


















Possible diagnosis Justification
Multiple myeloma
• 12-week history of back pain, worse with exercise and weight-bearing

• Weight loss

• Fatigue

• Recent infections
Metastatic disease
• 12-week history of back pain, worse with exercise and weight-bearing

• Weight loss

• Fatigue

• Recent infections
Leukaemia
• Weight loss

• Fatigue

• Recent infections
Lymphoma
• Weight loss

• Fatigue

• Recent infections

2. What additional questions do you need to ask Bruce?

A full history is required, including:


• more questions related to the nature of his fatigue

• over what duration of time has he lost weight and whether it was intentional

• any bruising, bleeding gums or nose bleeds

• any pains in other parts of his body (eg: headaches)

• any lumps or masses anywhere

• any unusual activities lately; sports, hobbies or work-related?

3.
a What is the significance of pain lasting for more than 12 weeks?

Simple mechanical back pain does not usually last more than 3–6 weeks (although it is possible). Pain lasting more than 12 weeks raises the suspicion that a diagnosis other than simple mechanical back pain should be considered, or that psychosocial issues may be complicating the clinical picture.


b What is the significance of Bruce’s weight loss and tiredness?

Weight-loss and tiredness is a red flag issue, suggesting a serious systemic abnormality.


c How relevant are the recent bouts of flu-like symptoms?

Recurring flu-like symptoms suggest immunosuppression.


d What is the significance of pain on weight-bearing, relieved by rest?

Pain on weight-bearing suggests possible bone weakening disease.


4. From the above information, can you narrow your differential diagnosis to the two most likely conditions you think this patient may be suffering?
• Multiple myeloma.

• Lymphoma.

5. Bruce is referred to a medical practitioner. What investigations are necessary for this patient?
• Full blood count and biochemistry should be done first.

• A lumbo—sacral spine X-ray is also indicated at this point.

• The results of these will determine the nature of further investigations.

6. What information do these results give you? What is the most likely diagnosis?

The X-ray illustrates osteopoenia with a pathological fracture of L-5.


The full blood count indicates that Bruce has a normocytic, normochromic anaemia, as well as an elevated erythrocyte sedimentation rate (ESR).


The biochemistry reveals a significant increase in plasma globulin levels.


These initial investigations are strongly suggestive of multiple myeloma.


7. What further testing is now required to confirm this? Why?

Confirmation of the diagnosis of multiple myeloma is now required. Bruce will thus require the following:


• Urine: assess for Bence Jones proteins.

• Protein electrophoresis: to identify the serum M-protein spike.
image Basically, the more immunoglobulin that is present, the more advanced the myeloma. Assessing changes and proportions of these proteins, particularly the ‘M’ or monoclonal immunoglobulin (produced by the tumour cells), helps track the progression of myeloma disease and response to treatment.

• Bone marrow biopsy — shows at least 10% abnormal, atypical, or immature plasma cells.

• Bone scan or radiographic studies to identify characteristic osteolytic bone lesions.

8. Describe the clinical features of the disorder identified in questions 6 and 7, and explain the pathophysiological mechanism for each.









Clinical feature Pathophysiological mechanism
Bone pain and pathological fractures
Multifocal destructive bone lesions throughout the skeleton (eg: vertebrae, ribs, skull, pelvis and femur)

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Chronic or recurring back pain

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