Topics in sports medicine
Metastatic Cancer of the Thoracic and Lumbar Spine Presenting as Mid- and Low Back Pain in a Long Distance Runner

https://doi.org/10.1016/j.jcm.2017.11.004Get rights and content

Abstract

Objective

The purpose of this case study is to describe the presentation of a patient with persistent back pain and a history of carcinoma.

Clinical Features

A 50-year-old female runner presented to a chiropractic office with persistent moderate low back and mid-back pain. She had a history of breast carcinoma. She had no positive neurologic signs or symptoms suggestive of radiculopathy. She denied any other health symptoms and received mild relief with only 1 office visit consisting of spinal manipulation, moist heat, and electrical stimulation. Although the patient experienced some pain relief after her chiropractic treatment, she continued to experience persistent mild pain in the thoracolumbar area.

Intervention and Outcome

Because of the patient’s lingering back pain, she was referred for lumbar spine radiographs. On evaluation of the radiographs, a missing right L3 pedicle was seen. A subsequent computed tomography scan of the lumbar spine revealed marked metastatic changes to the lower thoracic and upper lumbar spine. The patient was immediately referred to her oncologist. The metastatic changes had progressed to her liver, and she succumbed to the disease 6 months later.

Conclusion

This case highlights the importance of patient health history and further investigation of the red flag of persistent pain in patients with a history of carcinoma.

Introduction

Thoracic and lumbar spinal pain are 2 common complaints that patients present to the clinical chiropractic setting and are seen every day by various practitioners.1 It is relatively uncommon that low back pain represents a serious disease, but metastatic disease can present as low back pain, especially in patients with a history of carcinoma. It is these unique cases that the clinician must be wary of, in which common mid-back and low back pain represents a more serious pathologic condition, especially when the pain seems reticent to reliable and proven conservative care.

It is estimated that more than 85% of acute low back pain can be categorized as nonspecific, which includes lumbar strain and sprain, degenerative disk or facet process, and spinal stenosis or spondylolisthesis. Less than 5% is pathologic in origin, including neoplasia, infection, inflammatory arthritis, and visceral disease.2 It is these rare but extraordinary cases that can easily slip by the clinical practitioner until the symptoms are so severe they are impossible to ignore.

Approximately 5% to 6% of women with breast cancer present with distant spread, with bone representing the most common site of metastatic lesions. The risk of developing bone metastasis 10 years after initial diagnosis is 7% to 9%.3 It is imperative that clinicians be able to detect any clues in the patient’s history and physical examination to afford an early recognition of possible spinal metastasis and give the patient the best chance of survival. It is the purpose of this case report to describe the discovery of such a case in a seemingly healthy and active middle-aged athletic patient.

Section snippets

Case Report

A 50-year-old woman presented to a chiropractic office with moderate right lumbar and thoracic pain and mild pain in the right cervical and upper trapezius area. The patient had been seen 2 and 3 months previously for right lower thoracic and lumbar pain and could not recall any recent injury to these areas of her spine. However, she had been running many miles per day training for several half-marathons. She responded well to the previous treatment regime of spinal manipulation, moist heat,

Discussion

Spinal metastasis represents an extension of neoplastic disease, and early detection and accurate diagnosis provide the patient with the best chance of successful treatment and optimize the quality of an afflicted patient’s life. The vertebral column is the most common site of skeletal metastasis, with up to 70% of patients with cancer harboring secondary spinal disease.4 The spinal lesion represents the first manifestation of cancer in 12% to 20% of patients who present with symptoms related

Conclusion

This case illustrates the importance of follow-up with patients who currently have or previously had cancer. It also emphasizes that further diagnostic evaluation may be warranted in patients with mild but persistent symptoms who have a history of carcinoma.

Practical Applications

  • A detailed history and examination are imperative in helping to distinguish between benign musculoskeletal pain and metastatic musculoskeletal pain.

  • Further investigation, including detailed diagnostic imaging, is often needed

Acknowledgments

The author thanks Dr. Michael Schneider for his help with this manuscript.

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Contributorship Information

  • Concept development (provided idea for the research): J.P.L.

  • Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): J.P.L.

  • Literature search (performed the literature search): J.P.L.

  • Writing (responsible for writing a substantive part of the manuscript): J.P.L.

References (21)

  • RG Perrin et al.

    Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients

    Neurosurg Clin N Am

    (2004)
  • J Lin et al.

    Influence of hormone receptor status on spinal metastatic lesions in patients with breast cancer

    World Neurosurg

    (2016)
  • R. Mootz et al.

    Chapter VIII, content of practice

  • S Kinkade

    Evaluation and treatment of acute low back pain

    Am Fam Physician

    (2007)
  • Jensen et al.

    Incidence of bone metastases and skeletal-related events in breast cancer patients: a population-based cohort study in Denmark

    BMC Cancer

    (2011)
  • WB Jacobs et al.

    Evaluation and treatment of spinal metastases: an overview

    Neurosurg Focus

    (2001)
  • DI Boxer et al.

    Bone secondaries in breast cancer: the solitary metastasis

    J Nucl Med

    (1989)
  • TM Link et al.

    Spinal metastases. Value of diagnostic procedures in the initial diagnosis and follow-up

    Radiologe

    (1995)
  • WG Bradley et al.

    ACR Appropriateness Criteria®: Low Back Pain

  • R Rajul et al.

    Winking-owl sign - an uncommon presentation of spine metastasis

    Int J Clin Med Imaging

    (2016)
There are more references available in the full text version of this article.

Cited by (0)

View full text