Polymyalgia and low back pain: a common cause not to be missed

Abstract

Case reports PATIENT 1 A 65 year old man was admitted with a one month history of increasingly severe left sided sciatica. He had one previous episode of low back pain 40 years earlier. Four months before admission, a left inguinal hernia was repaired and following this he had complained of pain in the left testicle. His pain had rapidly increased day and night despite chiropractic treatment, and he complained of anorexia and weight loss, but no night sweats.On examination he appeared unwell and was in very severe pain, although with no focal spinal tenderness. All movements of the lumbar spine were reduced, with straight leg raising reduced on the left to 60°, with a positive sciatic stretch test. The left ankle jerk was absent. There were no abnormalities in the heart, lungs or abdomen.Blood tests showed a high erythrocyte sedimentation rate (ESR) of 91 mm 1st h with an anaemia of chronic disease. C reactive protein (CRP) was high at 70 mg/l, liver function tests, including alkaline phosphatase, and urea and electrolytes were normal, as were calcium and prostate specific antigen. Urine analysis on dipstick testing was normal. Although initial radiographs of the lumbar spine were unremarkable, apart from disc space narrowing only at level L5/S1, magnetic resonance imaging of the lumbar spine showed extensive abnormal signal within L5/S1 consistent with a malignancy (fig 1) and abnormal tissue surrounding the left L5 and S1 nerve roots.Abdominal ultrasound scan showed a probable carcinoma of the left kidney with a 4 cm lesion noted. Computed tomography of the chest and abdomen (fig 2) confirmed the renal lesion and showed bone deposits at T5, the left first rib, L4/L5 and S1. Left kidney biopsy was attempted, but insuYcient material was available for analysis. A bone biopsy confirmed a poorly diVerentiated renal carcinoma. The patient died two months later. PATIENT 2 This 70 year old woman presented with a four month history of low back pain that radiated into both groins, down the posterior aspect of both thighs to involve the knees, and as far as the feet. Morning stiVness was considerable. She was anorexic without weight loss.She had no previous history of low back pain.On examination, evidence was found of nodal generalised osteoarthritis. The lumbar spine showed a mild lumbar scoliosis but with a very good range of movement. Neurological examination of the legs showed normal straight leg raising, without focal tenderness, but subjective decrease in sensation in the right leg with bilateral absent ankle jerks. The rest of the examination was insignificant. A tentative diagnosis of nodal generalised osteoarthritis with lumbar spondylosis producing bilateral sciatica was made. Magnetic resonance imaging of the thoracic and lumbar spine showed very marked disc prolapse and protrusion at the level of L3/L4, involving both L4 nerve root sheaths. There was also disc prolapse at L2/L3 and, to a lesser extent, at T8 /T9. Ann Rheum Dis 1999;58:462-464

Paraneoplastički neurološki sindrom uz karcinom bubrega

“…There are no particular clinical patterns, imaging and laboratory abnormalities specific for PNS. In addition, PNS usually occur in patients with lung carcinoma, neuroblastoma or thymoma, but other tumors and malignant lymphomas should be considered as well, as shown in this case [1,[5][6][7][8][9] .…”

A case study of back pain and renal cell carcinoma

“…The initial radiographs had been examined by a medical radiologist, a chiropractic radiologist, and a practicing doctor of chiropractic; and no pathology was determined to exist on the plain films. Although abdominal ultrasound is currently considered an important diagnostic modality, researchers state, 8 "To our knowledge the 'pick-up rate' of renal cell carcinoma by abdominal ultrasound has not been established, but will depend on tumor size and position, operator skill and body habitus." Hopkinson 8 also admonishes the practitioner that a normal plain film radiograph cannot be considered to exclude metastatic disease to bone; advanced imaging is necessary to uncover RCC, showing that a chiropractor's role as a primary care physician certainly does include the process of clinical reasoning and referral when the clinical picture proves equivocal.…”

“…7 Chiropractors ought to be aware of the similarity of presentation between vertebral subluxation complexrelated complaints and RCC-related symptoms, such as include sciatica and extreme pain (especially at night), and also to include anorexia, weight loss, and night sweats. According to Hopkinson,8 "In patients with symptoms suggestive of polymyalgia rheumatica, underlying renal malignancy should always be considered." He further advises suspicion in any case of new-onset back pain with an elderly patient.…”