Cancer, Infection, Fracture
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REVIEW KRZYSZTOF SIEMIONOW, MD MICHAEL STEINMETZ, MD GORDON BELL, MD Department of Orthopaedic Surgery, Department of Neurosurgery, and Cleveland Vice-Chairman, Department of Orthopaedic Cleveland Clinic Clinic Center for Spine Health, Surgery, and Associate Director, Cleveland Cleveland Clinic Clinic Center for Spine Health, Cleveland Clinic HAKAN ILASLAN, MD ROBERT F. MCLAIN, MD Department of Radiology, Cleveland Clinic Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Director of Spine Fellowship Program, Depart- ment of Orthopaedic Surgery and Cleveland Clinic Center for Spine Health, Cleveland Clinic Identifying serious causes of back pain: Cancer, infection, fracture ■■ ABSTRACT ack pain is one of the most common com- B plaints that internists and primary care Most patients with back pain have a benign condition, physicians encounter.1 Although back pain is but tumors, infections, and fractures must be considered nonspecific, some hallmark signs and symp- during an initial evaluation because overlooking them toms indicate that a patient is more likely to can have serious consequences. This article discusses the have a serious disorder. This article contrasts presentation and diagnostic strategies of these serious the presentation of cancer, infections, and causes of back pain. fractures with the more common and benign conditions that cause back pain and provides ■■ KEY POINTS guidance for diagnosis. A primary tumor or metastasis to the spine tends to ■ UNCOMMON, BUT MUST BE CONSIDERED cause unremitting back pain that worsens at night and is Although a variety of tissues can contribute accompanied by systemic disease and abnormal labora- to pain—intervertebral disks, vertebrae, liga- tory findings. ments, neural structures, muscles, and fascia— and many disorders can damage these tissues, Infection typically causes focal pain, an elevated eryth- most patients with back or neck pain have a rocyte sedimentation rate (the most sensitive laboratory benign condition. Back pain is typically caused test) and C-reactive protein level, and sometimes neuro- by age-related degenerative changes or by mi- nor repetitive trauma; with supportive care logic signs and symptoms. and physical therapy, up to 90% of patients with back pain of this nature improve substan- Fractures cause focal pain and should be suspected tially within 4 weeks.2 especially in older white women and patients who take Serious, destructive diseases are uncommon corticosteroids or who have ankylosing spondylitis. causes of back pain: malignancy, infection, an- kylosing spondylitis, and epidural abscess to- Plain radiography can help detect fractures, but magnetic gether account for fewer than 1% of cases of resonance imaging is needed to evaluate spinal tumors, back pain in a typical primary care practice. But their clinical impact is out of proportion soft tissue infections, and epidural abscesses, and to to their prevalence. The fear of overlooking a further evaluate neural compression due to fractures. serious condition influences any practitioner’s approach to back pain and is a common rea- son for ordering multiple imaging studies and consultations.3 Therefore, the time, effort, and resources invested in ruling out these disorders is considerable. Whether a patient with back pain has an ominous disease can usually be determined with a careful history, physical examination, CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • NUMBER 8 AUGUST 2008 557 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. BACK PAIN Cancer pain is persistent and progressive table 1 Pain from spinal cancer is often different from Features associated with degenerative idiopathic back pain or degenerative disk dis- disk disease and with neoplastic disease ease (TABLE 1). Benign back pain often arises from a Degenerative disk disease known injury, is relieved by rest, and increases Pain that: with activities that load the disk (eg, sitting, Developed after known injury getting up from bed or a chair), lumbar flexion Increases with activity with or without rotation, lifting, vibration (eg, Is aching Subsides with rest, physical therapy, nonsteroidal riding in a car), coughing, sneezing, laughing, anti-inflammatory drugs and the Valsalva maneuver. It is most com- Laboratory studies are typically normal monly focal to the lumbosacral junction, the Patient may have a history of spine surgery lumbar muscles, and the buttocks. Pain due to injury or a flare-up of degenerative disease typ- Neoplastic disease ically begins to subside after 4 to 6 weeks and Age > 50 years responds to nonsteroidal anti-inflammatory Pain is not relieved by rest or recumbency 10 Anemia drugs and physical therapy. Elevated erythrocyte sedimentation rate, C-reactive protein level In contrast, pain caused by spinal neopla- Failure to improve with conservative therapy sia is typically persistent and progressive and is History of cancer not alleviated by rest. Often the pain is worse Pain worsens at night at night, waking the patient from sleep. Back pain is typically focal to the level of the lesion ADAPTED FROM INFORMATION PRESENTED IN DEYO RA, DIEHL AK. CANCER AS A CAUSE OF BACK PAIN: FREQUENCY, CLINICAL PRESENTATION, AND DIAGNOSTIC STRATEGIES. J GEN INTERN and may be associated with belt-like thoracic MED 1988; 3:230–238 AND PATEL RK, SLIPMAN CW. LUMBAR DEGENERATIVE DISK DISEASE. pain or radicular symptoms of pain or weakness EMEDICINE. WWW.EMEDICINE.COM/PMR/TOPIC67.HTM. in the legs. A spinal mass can cause neurologic signs or symptoms by directly compressing the and appropriate diagnostic studies. Once a se- spinal cord or nerve roots, mimicking disk The spine is rious diagnosis is ruled out, attention can be herniation or stenosis.11,12 one of the most focused on rehabilitation and back care. Pathologic fractures resulting from verte- Back pain can also be due to musculoskele- bral destruction may be the first—and unfor- common sites tal disorders, peptic ulcers, pancreatitis, pyelo- tunately a late—presentation of a tumor. of metastasis nephritis, aortic aneurysms, and other serious conditions, which we have discussed in other Ask about, look for, articles in this journal.4–6 signs and symptoms of cancer In taking the history, one should ask about ■ SPINAL CANCER AND METASTASES possible signs and symptoms of systemic dis- ease such as fatigue, weight loss, and changes Since back pain is the presenting symptom in bowel habits. Hemoptysis, lymphadenopa- in 90% of patients with spinal tumors,7 neo- thy, subcutaneous or breast masses, nipple plasia belongs in the differential diagnosis of discharge, atypical vaginal bleeding, or blood any patient with persistent, unremitting back in the stool suggest malignancy and should pain. However, it is also important to recog- direct the specific diagnostic approach.13 A nize atypical presentations of neoplasia, such history of cancer, even if remote, should raise as a painless neurologic deficit, which should suspicion, as should major risk factors such as prompt an urgent workup. smoking. The spine is one of the most common sites Because most spinal tumors are metastases, of metastasis: about 20,000 cases arise each a clinical examination of the breast, lungs, ab- year.8 Brihaye et al9 reviewed 1,477 cases of domen, thyroid, and prostate are appropriate spinal metastases with epidural involvement starting points.14 The spine should be exam- and found that 16.5% arose from primary tu- ined to identify sites of focal pain. A neuro- mors in the breast, 15.6% from the lung, 9.2% logic examination should be done to evaluate from the prostate, and 6.5% from the kidney. any signs of neurologic compromise or abnor- 558 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • NUMBER 8 AUGUST 2008 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. SIEMIONOW AND COLLEAGUES Spinal metastasis: CT study Spinal metastasis: MRI study The ESR and FIGURE 1. A 43-year-old man with a 2-week CRP are almost history of progressive back pain and an always elevated abdominal mass. Sagittal CT scan shows an FIGURE 2. A 63-year-old woman with osteolytic lesion of the L3 vertebral body history of hepatocellular carcinoma who with systemic (arrow). The primary tumor was renal. presented with bilateral leg weakness and neoplasia Fracture of the vertebral end plate (arrow- debilitating back pain. T2-weighted MRI heads) may cause first symptoms of pain. shows pathologic compression fracture of the L2 vertebral body with retropulsion of fracture fragments into the canal and mal reflexes. Signs or symptoms of spinal cord severe central canal stenosis (arrow). compression should be investigated immedi- ately. cell count and chemistry panel. If laboratory Cancer usually elevates the ESR, CRP studies reveal anemia, hypercalcemia, and If cancer is suspected, initial tests should in- elevated levels of alkaline phosphatase, con- clude a complete blood cell count, erythrocyte cern should increase. Chest radiography, ab- sedimentation rate, C-reactive protein level, dominal computed tomography (CT) (FIGURE urinalysis, prostate-specific antigen level, and 1), and mammography for women are needed fecal occult blood testing. Normal results can if laboratory results are abnormal. Plain radio- considerably relieve suspicion of cancer: the graphs are the first imaging study of the spine erythrocyte sedimentation rate and C-reactive to obtain. Compression fractures, soft