A Lung Cancer Patient Complaining Of Back Pain

A 63-year-old male with a diagnosis of non-small-cell lung cancer, undergoing weekly chemotherapy and radiation to a left upper lobe mass, presents to your office. He complains of dull, non radiating back pain in the lower thoracic/upper lumbar area. He denies trauma or any new activities. He has no associated weakness or paresthesias. He denies difficulties with bowel or bladder function.
What is you initial diagnostic and/or therapeutic approach to this patient?

A) MRI of thoracic and lumbar spine and NSAIDs.
B) Plain films of the thoracic and lumbar spine a
COX-2 inhibitor with a 2-week follow-up.
C) Plain films of the thoracic spine and NSAIDs.
D) Prescription for physical therapy and NSAIDs.
E) Urinalysis with culture and antibiotics.

Answer:



A: MRI of thoracic and lumbar spine and NSAIDs.

Explanation: This is not your average back pain. Any patient with active malignancy complaining of back pain should be investigated for metastasis. While a plain film of the spine may be useful, the gold standard is MRI. The real emergency is spinal cord impingement. Spinal cord compression may occur from direct extension of metastatic disease from the vertebrae or extension from retroperitoneal or paravertebral disease. Frequently, the pain predates neurological symptoms, and because of the potential for severe, adverse outcomes, you want to catch the disease early to prevent chronic impairment.