Case reportMalignant Myeloma of the Spine
Introduction
John presented to the spinal assessment clinic at a district general hospital in September 2001 with what proved to be a malignant myeloma of T12. The case highlights the difficulty of detecting serious spinal pathology in the early stages and that serious pathology may in the early stages appear to respond to physiotherapy. In the later stages John's case vividly illustrates a number of the red flags associated with serious spinal pathology (CSAG, 1994).
Section snippets
The Patient
John was a 64-year-old man, leaning heavily on the reception desk and obviously in a great deal of discomfort when first seen, but was trying hard to smile. He appeared unwell with a sallow complexion, slightly dishevelled appearance and poorly fitting clothes. He moved to a chair in reception and sat down and soon began to half lie on to the next chair. Within two minutes he stood up and leant against a cupboard. Clearly his behaviour demonstrated excruciating pain.
He came into the treatment
Subjective Assessment
John's problems had begun 10 months previously. His initial symptoms were abdominal pain and increasing problems with constipation despite no changes in medication. There was no previous history of these symptoms. Thoraco-lumbar pain and radiating pain to the left chest wall, which he attributed to a lifting injury, began shortly afterwards.
His general practitioner had referred John to physiotherapy, with a diagnosis of simple mechanical back pain, and treatment began on February 2. The first
Objective Assessment
Because of his excruciating pain the objective assessment was modified. John's gait was slightly unco-ordinated, with a suggestion of high stepping. In standing he was unable to perform active lumbar movements. He was unable to lie supine or prone. In right side lying straight-leg-raise was tested and both left and right increased abdominal pain. Sensation was tested and it was found that there was severe blunting extra-segmentally to light touch from the waist down. Knee reflexes were brisk,
Implications for Practice
John's case vividly illustrates the trad-itionally recognised red flags in the presence of a malignant tumour of the spine. His case also shows that abdominal pain and constipation for no apparent reason may indicate a malignant tumour of the spine.
Myeloma is a malignancy which affects plasma cells. The commonest sites to be affected are the bone marrow of the spine, pelvis, rib cage and skull. The uncontrolled growth of myeloma cells leads to the destruction of the skeleton, bone marrow
Early Stage Management
In the early stages it is almost impossible to detect serious spinal pathology. The Clinical Standards Advisory Group published guidelines in May 1994, which sought to improve the standards of clinical care for patients with back pain. Contained within these guidelines is a set of diagnostic indicators which include those for possible serious spinal pathology — more commonly known as ‘red flags’.
The red flags are as follows:
- ▪
Age of onset up to 20 or over 55 years.
- ▪
Violent trauma (fall from
References (5)
Back Pain: Report of a Clinical Standards Advisory Group on Back Pain
(1994)Multiple Myeloma: A concise review of the disease and treament options
(1996)
Cited by (8)
A Biomechanical Investigation of Selected Lumbopelvic Hip Tests: Implications for the Examination of Walking
2016, Journal of Manipulative and Physiological TherapeuticsCitation Excerpt :This study was approved by the Human subjects, University of Central Lancashire, Preston, UK. Prior to testing, each participant completed a health screening questionnaire to confirm that they were injury free, that they had no diagnosed balance disorder or leg length discrepancy, and that they did not have any preexisting medical condition that would prevent them from participating.22,23,23–26 Subsequently, 14 healthy male participants were recruited (age, 20.5 ± 2.0 years; height, 1.76 ± 0.13 m; mass, 73.9 ± 9.0 kg) who had no pain or neuromusculoskeletal disorder.
Mechanical diagnosis and therapy (MDT) approach for assessment and identification of serious pathology
2011, Manual TherapyCitation Excerpt :Altogether, these history findings have a high sensitivity (0.98) (Deyo et al., 1992; Lurie, 2005). In addition she had abdominal pain, a possible early sign of serious pathology (Greenhalgh and Selfe, 2003). Her weight loss of 13% over 12 months is a Red Flag (Greenhalgh and Selfe, 2006).
Margaret: A tragic case of spinal Red Flags and Red Herrings
2004, PhysiotherapyAre we missing any patients with serious spinal pathology?
2013, International Journal of Therapy and RehabilitationRed Flags II: A guide to solving serious pathology of the spine
2009, Red Flags II: A Guide to Solving Serious Pathology of the SpineRed Flags II
2009, Red Flags II
- 1
Sue Greenhalgh MA GradDipPhys MCSP is a consultant physiotherapist in Bolton Primary Care Trust.
- 2
James Selfe PhD MA GradDipPhys MCSP is a senior lecturer in the Division of Physiotherapy, School of Health Studies, University of Bradford, and a visiting physiotherapy lecturer at Satakunta Polytechnic, Pori, Finland.