A 76-year-old man comes to the office with a 2-month history of progressive low back pain. The pain is relatively constant and nagging and is unrelieved by rest or position changes. It is especially bad at night and interferes with sleep. The patient has taken acetaminophen and ibuprofen without relief. Medical history is significant for hypertension and osteoarthritis affecting the knees and hands. The patient used intravenous drugs occasionally when he was younger but not for 30 years. Which of the following processes is most likely responsible for this patient's back pain?

Question

A 76-year-old man comes to the office with a 2-month history of progressive low back pain.  The pain is relatively constant and nagging and is unrelieved by rest or position changes.  It is especially bad at night and interferes with sleep.  The patient has taken acetaminophen and ibuprofen without relief.  Medical history is significant for hypertension and osteoarthritis affecting the knees and hands.  The patient used intravenous drugs occasionally when he was younger but not for >30 years.  Which of the following processes is most likely responsible for this patient's back pain?

Quizplus · Accepted Answer

11ec160b_3a66_ce25_9249_d3c2dcd9142b_MD0001_00 Back pain is common, and the majority of cases are due to benign skeletal (eg, osteoarthritis, spinal stenosis, disc herniation) or muscular (eg, muscle strain) conditions. The most common causes of back pain generally worsen with activity and improve with rest, postural modifications (eg, spinal stenosis worsens with back extension and is relieved with flexion), and analgesic therapy. However, this patient's constant back pain that fails to improve with positional changes, rest, or analgesics is concerning for a more serious condition (infection, malignancy). This pattern of pain in an older patient (age >50) without a recent history of intravenous drug use should raise suspicion for a neoplastic process, particularly if the pain is worse at night (nocturnal pain). Other features that raise concern for malignancy include a personal history of cancer, weight loss, neurologic deficits (eg, weakness), and point tenderness on the spinous processes. Malignancies with a propensity for bony metastasis include Prostate, Breast, Kidney, Thyroid, and Lung (mnemonic: Pb KTL, or "lead kettle"). Prostate cancer is the most common malignancy in older men and frequently metastasizes to the axial skeleton and femur. (Choice A) Degenerative disorders in the spine (eg, facet osteoarthritis) are typically relieved with rest and while in bed overnight; this patient's constant pain that persists overnight is more worrisome for malignancy. (Choice B) Vertebral osteomyelitis (pain at rest, focal tenderness) and epidural abscess (nerve root compression, radicular symptoms) can be associated with intravenous drug use but typically occur following recent use, not decades later, and are usually associated with systemic symptoms (eg, fever, night sweats). (Choice C) Inflammatory back pain (eg, spondyloarthropathy) is characterized by slowly progressive pain that is often worse at night. However, it is associated with prolonged morning stiffness (eg, hours) and improves with exercise. In addition, onset almost always occurs at age <45. (Choice E) Back pain may be psychogenic (eg, factitious, malingering). Evidence of secondary gain (eg, litigation/compensation) and an unusual pattern of signs and symptoms can help identify these patients. Educational objective: Clinical features that suggest a malignant cause of back pain include persistent pain at night, no relief with rest, onset at age >50, and systemic symptoms. Common malignancies with a propensity for bony metastasis include prostate, breast, kidney, thyroid, and lung.

A 76-Year-Old Man Comes to the Office with a 2-Month