Investigate back pain after cancer

Severe back pain in a former cancer patient causes concern. Dr Gwen Lewis explains.

Josie was an ebullient 78-year-old woman who was very involved in the community.

She had developed breast cancer 10 years before and was hypertensive. The cancer had been successfully treated with surgery and radiotherapy and her BP was well controlled.

She was generally uncomplaining and so the day she attended surgery with severe lower back pain and pain in her left leg, I was concerned.

Josie said she had been cutting flowers three weeks earlier when she had slipped on some wet leaves, landing on her buttocks. As was usual for her, she assumed that the pain would improve, but it had since forced her to abandon her work. When the pain began to wake her at night, she decided to seek help.

When she entered my room, Josie was in obvious discomfort. Examination revealed little except that her movements were severely limited in all directions.

Even though 10 years had elapsed since her cancer diagnosis, I thought she might have developed bone metastases.

Bone metastases
All cancers can metastasise to the bone, but bone metastases of breast, lung and thyroid carcinomas are more common.

I arranged an X-ray of the lumbar spine and hips that day, prescribed analgesia and arranged an appointment the following week.

At the review, she was still in pain due to her reluctance to take the prescribed analgesics, but I was relieved by the X-ray report, which showed no bony metastases.

Instead, it revealed severe generalised osteoporosis with wedging of lumbar vertebral bodies and a wedge fracture of the first lumbar vertebra.

Vertebral fractures at T4 or above suggest malignancy rather than osteoporosis.

The skeletal weakness of osteoporosis can lead to fractures, particularly after trauma, and these are the main cause of pain in the condition.

Pain is experienced in the bones or muscles, often of the back. Vertebral compression fractures are common.

Management
I arranged a bone density scan which reported a T-score of -2.6.

Josie had no apparent risk factors for osteoporosis.

She had never smoked, she drank alcohol occasionally, she was very active and she had never taken steroids, so I was unable to find a cause.

I commenced Josie on risedronate 35mg weekly plus calcium and vitamin D, recommending analgesia as necessary, and explained the treatment would be long term.

Josie's back pain has gradually improved and she will be scanned again in due course to assess the effects of treatment. She's very happy to be back to her busy self.

Dr Lewis is a GP in Windsor, Berkshire.

Lessons learnt

  • Osteoporosis may become evident due to pain following a fracture.
  • Osteoporosis is diagnosed by dual energy X-ray absorptiometry.
  • A T-score less than -2.5 diagnoses osteoporosis and a T-score between -1.0 and -2.5 diagnoses osteopenia.
  • Management includes risk factor modification, exercise, calcium and vitamin D supplementation, drug therapy to preserve bone mass or stimulate bone formation and analgesia.

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