Malignant Myeloma of the Spine

doi:10.1016/S0031-9406(05)60006-5

Physiotherapy

Volume 89, Issue 8, August 2003, Pages 486-488

https://doi.org/10.1016/S0031-9406(05)60006-5 Get rights and content

Summary

A patient diagnosed with simple mechanical back pain appeared to respond to physiotherapy. His pain later increased and subsequent investigation revealed a malignant spinal tumour. This was surgically removed and he resumed many activities of daily living. Retrospectively, this patient displayed from the outset several symptoms diagnostic of serious pathology.

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)

Clinical Standards Advisory Group
Back Pain: Report of a Clinical Standards Advisory Group on Back Pain
(1994)
BGM Durie
Multiple Myeloma: A concise review of the disease and treament options
(1996)

There are more references available in the full text version of this article.

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A Biomechanical Investigation of Selected Lumbopelvic Hip Tests: Implications for the Examination of Walking
2016, Journal of Manipulative and Physiological Therapeutics
Citation 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.
The purpose of this study was to compare lumbopelvic hip ranges of motion during the Trendelenburg, Single Leg Squat, and Corkscrew Tests to walking and to describe the 3-dimensional lumbopelvic hip motion during the tests. This may help clinicians to select appropriate tests when examining gait.
An optoelectronic movement analysis tracking system was used to assess the lumbopelvic hip region of 14 healthy participants while performing Trendelenburg, Single Leg Squat, and Corkscrew Tests and walking. The lumbopelvic hip 3-dimensional ranges of movement for the clinical tests were compared with walking using a repeated-measures analysis of variance with pairwise comparisons.
No significant differences were found between the pelvic obliquity during the Trendelenburg Test and walking (Trendelenburg Test: L, 11.3° ± 4.8°, R, 10.8° ± 5.0° vs walk: L, 8.3° ± 4.8°, R 8.3° ± 5.1°, L, P = .143, R, P = .068). Significant differences were found between the hip sagittal plane range of movement during the Single Leg Squat and walking (Single Leg Squat: L, 44.2° ± 13.7°, R, 41.7° ± 10.9° vs walk: 38.6° ± 7.0°, R 37.8° ± 5.1°, P < .05), the hip coronal plane range of movement (Single Leg Squat: L, 9.1° ± 5.8°, R, 9.0° ± 4.6° vs walk: L, 9.4° ± 2.3°, R 9.5° ± 2.0°, P < .05), and the hip coronal plane range of movement during the Corkscrew Test and walking (Corkscrew: L, 5.7° ± 3.3°, R, 5.7° ± 3.2° vs walk: L, 9.4° ± 2.3°, R 9.5° ± 2.0°, P < .05).
The results of the present study showed that, in young asymptomatic participants with no known lumbopelvic hip pathology, the pelvic obliquity during the Trendelenburg Test and walking is similar. During the Single Leg Squat, the hip moved more in the sagittal plane and less in the coronal plane when compared with walking. There was more movement in the hip transverse plane movement during the Corkscrew Test than during walking. These results suggest that for the Trendelenburg Test to be interpreted as normal, the pelvis should achieve at least 10° of pelvic obliquity; during the Single Leg Squat, the hip should move through 43° in the sagittal plane and under 10° in the coronal plane; and for the Corkscrew Test to be interpreted as normal, the hip should move through 6° of rotation and the trunk through 27° of rotation.
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2011, Manual Therapy
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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
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Objective This case illustrates how easily patient misattribution can influence the clinical reasoning process and it alerts physiotherapists to safeguard from the influences of Red Herrings.
Design It is the second in a series of case studies considering patients with serious spinal pathology.
Setting This paper considers the case of a 49year old lady who was referred to a Spinal Assessment Clinic in a district general hospital. The clinic was established specifically to deal with more complex spinal patients, identifying those at risk of chronicity, surgical cases or those with more complex pathology. Unfortunately this case was subsequently diagnostically triaged as serious spinal pathology.
Conclusion As misattribution of symptoms by the patient is common, it is essential that the clinician considers a thorough subjective and objective assessment. When drawing inferences from the findings it is vital to stand back and consider if the attributed cause and effect is an inherent likelihood and consider whether there may be important information missing.
Are we missing any patients with serious spinal pathology?
2013, International Journal of Therapy and Rehabilitation
Red Flags II: A guide to solving serious pathology of the spine
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Red Flags II
2009, Red Flags II

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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.

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Case reportMalignant Myeloma of the Spine