Case study: Progressive low back pain in a 47-year-old man

presentation

A 47-year-old man has had persistent and progressive back pain, primarily in the lower lumbar region, radiating to the right leg for about eight weeks. [1]

The anamnesis shows a slipping of the vertebrae that has been known for many years (spondylolisthesis L5/S1, grade 1, slipping up to 25%). Due to the symptoms of bilateral L5 root irritation, the man had already been treated conservatively a year earlier in a specialized spine department.

Physical examination

The test shows:

  • Hyperlordosis of the lumbar spine with total fixation in forward tilt

  • Hard paravertebral muscle tension

  • Pain when tipping over and leaning back

  • Free sacroiliac joints

  • Multi-chambered pressure and touch pain at the lower end of the lumbar spine

  • Negative Lasègue sign and Bragard test

  • No motor and sensory deficits

imaging

The X-ray of the lumbar spine in 2 planes (standing) shows a spondylolisthesis L5/S1 according to Meyerding grade I.

MRI of the lumbar spine suggests a destructive mass in the third lumbar vertebra; Herniated disc L5/S1 with bilateral L5 root irritation

CT scan of the lumbar spine: Osteolysis in the third lumbar vertebra

diagnosis and development

The radiological findings raised the suspicion of a lymphoma or plasmacytoma. However, according to the orthopedists, laboratory tests at the time showed no signs of inflammation or bone loss. In addition, the patient did not present with general symptoms such as fever, night sweats or involuntary weight loss in the sense of B symptoms.

A CT-guided biopsy of the third lumbar vertebra for histological clarification revealed a Squamous cell carcinoma of the thymus.

CT scan of the thoracic and upper abdominal organs and scintigraphy of the skeleton showed multiple bone metastases at the level of the right 8th rib and the left 9th rib, in the sternal manubrium, in the 3rd and 4th lumbar vertebrae, in the acetabulum, in the sit bone and the pelvic bone , both right, and a cystic lesion in segment IVa of the liver and suspicious hilar lymph node enlargement on the right.

CT scan of soft tissues of the neck and thorax with contrast medium showed a large mass (4.8 × 8.5 × 8 cm) in the anterior superior mediastinum, thymic compartment (suspicion of thymoma or lymphoma).

The patient died a few months later from liver failure.

discussion

As the authors point out [1]The reporting of this case is intended to raise awareness that a reassessment must always be carried out, even in the case of a known orthopedic disease but insufficient therapeutic response, in order to identify concomitant diseases or serious new diseases at an early stage. Their case, they explain, reflects two extremes: chronic back pain is a widespread disease; Thymus carcinoma, on the other hand, is very rare and represents an absolute exception as a differential diagnosis in acute or chronic back pain.

Both thymomas and thymic carcinomas develop from the epithelial tissue of the thymus. These are the most common subtypes, less often carcinoids, thymolipomas, lymphomas and germ cell tumors.

With an incidence of about 3.2 per million inhabitants/year, thymus carcinoma is a rare tumor. These malignant mediastinal tumors are often discovered incidentally during chest radiological examinations. About 45% of patients have paraneoplastic myasthenia gravis.

Since metastases to the spine—particularly the lumbar spine—are the most common metastatic target of malignancy, this possibility should be considered. In addition to a complete anamnesis, if the type of tumor is unknown, an early biopsy should be performed to identify the primary tumor due to its prognostic importance.

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