Endgames Picture Quiz

Another patient with low back pain

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3510 (Published 14 June 2012) Cite this as: BMJ 2012;344:e3510
  1. B O’Leary, core medical trainee,
  2. G Eminowicz, specialty registrar in clinical oncology,
  3. M E Powell, consultant in clinical oncology,
  4. S Pacey, honorary consultant in medical oncology
  1. 1Department of Oncology, University of Cambridge, Box 193 (R4), Addenbrooke’s Hospital, Cambridge CB2 0QQ, UK
  1. Correspondence to: S Pacey simonpacey{at}medschl.cam.ac.uk

A 52 year old man was admitted to our oncology unit owing to the side effects of ongoing chemotherapy; he also gave a 10 day history of back pain. In 2008, after a bowel resection for colonic obstruction, he had been diagnosed with diffuse large B cell lymphoma. This was treated with eight cycles of R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) and a complete response was achieved.

He relapsed in 2010, when he presented with shortness of breath, lethargy, and weight loss. Imaging confirmed a pleural mass, lesions in the lung and liver, and lytic bone lesions. He received three cycles of RICE chemotherapy (rituximab, ifosfamide, carboplatin, and etoposide). After achieving a partial response he was treated with high dose cytarabine and etoposide chemotherapy to stabilise the disease. While he was an inpatient, with chemotherapy toxicity, he reported lower back pain and difficulty lifting his right leg, which had got worse over the past 10 days. The pain started suddenly when walking, woke him at night, and on walking radiated around to his umbilicus. On examination he was in pain—especially when he lifted the right leg—but had normal tone, power, reflexes, and sensation in both legs. A plain lumbar spine radiograph showed multiple lytic lesions, as expected. He therefore underwent magnetic resonance imaging of the whole spine (fig 1).

Fig 1 T2 weighted magnetic resonance imaging of lumbar spine

Questions

  • 1 What is the diagnosis?

  • 2 What is the most appropriate initial management?

  • 3 What are the subsequent options for definitive management?

  • 4 How should the patient …

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