Endgames Case Review

A man with a short history of lower back pain

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1722 (Published 07 April 2016) Cite this as: BMJ 2016;353:i1722
  1. Alison Edwards, foundation year 2 doctor1,
  2. Preethi Nalla, specialist registrar in diabetes and endocrinology1,
  3. L D Premawardhana, consultant in diabetes and endocrinology1
  1. 1Section of Endocrinology, Ysbyty Ystrad Fawr, Ystrad Fawr Way, Ystrad Mynach, Caerphilly CF82 7EP, UK
  1. Correspondence to: A Edwards Alison.Edwards6{at}wales.nhs.uk

A previously fit and well 69 year old man presented to his general practitioner with a four week history of lower back pain. He had no history of trauma, took no regular drugs, was an ex-smoker, and did not drink alcohol. Physiotherapy, sought privately, had provided no benefit. His GP prescribed painkillers and reviewed him two weeks later, at which point, with no improvement in symptoms, spinal radiography was organised. Radiography showed multiple compression fractures of vertebrae T11-L2 (fig 1; arrows).

Fig 1 Plain radiograph showing multiple compression fractures of vertebrae T11-L2 (arrows)

The GP arranged blood tests and referred the patient to hospital for assessment. On further questioning, he had recently lost weight and had loss of appetite. Pallor was noted on examination. There were no neurological findings (in particular, no signs of spinal cord compression) and other systems examinations were normal. Rectal examination showed a smooth, enlarged prostate, with normal anal tone and sensation.

Blood tests showed normocytic anaemia (haemoglobin 99 g/L (reference range 130-180), mean cell volume 95 fL (80-100)), and normal white cell and platelet counts. A renal profile was normal, bone profile showed protein 86 g/L (60-80), albumin 35 g/L (35-50), globulin 51 g/L (22-43), alkaline phosphatase 163 U/L (30-130), adjusted calcium 2.74 mmol/L (2.20-2.60), and phosphate 1.64 mmol/L (0.80-1.50). Imaging studies comprised whole spine magnetic resonance imaging (MRI); computed tomography of the thorax, abdomen, and pelvis; and a skeletal survey (fig 2).

Fig 2 Skull radiograph (with contrast) done as part of skeletal survey

Questions

  1. What is the diagnosis?

  2. What additional investigations would aid diagnosis?

  3. What complications may arise?

  4. How should this patient be managed?

Answers

1. What is the diagnosis?

Short answer

Multiple myeloma.

Discussion

The spinal radiograph shows pathological fractures of T11-L2 (fig 1), suggestive of metastatic disease (for example, from primary kidney, thyroid, or gastrointestinal cancer) …

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