Case #87 "My Aching Back"
by Charlene Babcock Irvin, MD, FACEP  

A 42 y/o female with a history of chronic renal failure presents with increased back pain. She was recently diagnosed with an infection in her back, and they drained some fluid. She woke up this morning with increased back pain, and wants something for the pain. The pain starts in her back, and radiates down both legs. It’s not severe when she is lying there, but now it’s too severe to walk. She is a very poor historian, and it is difficult to get answers to questions.

ROS: No fever, chills, or vomiting. She has had 10 lbs wt loss since her back problem started. She is not sure about weakness as she is in too much pain to walk. No weakness yesterday. No new numbness. No bowl or bladder problem (she never makes any urine –she is a dialysis patient). No rashes. No history of trauma. Pain occurs only with walking.

PMH: Chronic Renal Failure, dialysis was due today (Mon-Wed-Fri). She also has HTN (the reason for her renal failure).

Meds: She doesn’t know all the names, but she knows she is on blood pressure medications, and Vicodin. The Vicodin had been working, but the pain was so severe this AM she didn’t even try them. She just called EMS.

SH: No history of drug or alcohol abuse. Back pain started 3 months ago when she was moping in a restaurant. She is currently unemployed.

PE: WD thin female lying still on the bed in no respiratory distress. BP 200/120 HR=110 RR=20 Temp =97.6 Oxygen Sat=96% on Room Air.

HEENT: Unremarkable

Heart: RRR, easily audible heart tones. Systolic Murmur heard at Left upper sternal boarder

Lungs: Clear Bilaterally

Abd: Thin. No scars.

Ext: Fistula in Left upper arm with normal thrill

Back: No erythema. No scars. Boney tenderness is noted at lower lumbar spine area.

Neurologic: Pain with passive straight leg rising bilaterally. No weakness to plantar flexion/extension. She is not able to lift legs independently or ambulate second to pain. Reflexes are symmetric and normal.

Questions:

1. How much radiation is in a lumbar x-ray?

2. What are the ‘red flags’ for back pain?

3. What cancer is most likely associated with metastatic spine cancer?

4. What are the risk factors for compression fracture?

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