Low Backache in a 70-year-old Woman

A 70-year-old woman presented with a 1-year history of progressive low back pain. The onset was insidious without antecedent trauma. She was earlier seen at another institution, where a sacral lesion was found and a CT-guided needle biopsy was performed twice with inconclusive results. The pain subsequently worsened and was exacerbated by activities, especially flexion of the hip, and was relieved by rest and oral and transdermal narcotics. She had occasional nocturnal pain and paresthesias, radiating in the posterior right lower extremity. She also complained of constipation but did not have any urinary symptoms or rectal bleeding. She denied any constitutional symptoms. Nine years previously, she had been treated for a rectal adenocarcinoma by a low anterior resection, adjuvant 5-fluorouracil, and radiotherapy (50 Gy with a four-field box technique). She had a 30-pack-years’ history of smoking but had quit 10 years earlier. The remainder of her medical history was noncontributory, except for thyroxine supplement for hypothyroidism and multiple episodes of subacute intestinal obstruction. Her family history was significant for lung carcinoma in her father and son, colon carcinoma in her daughter, and colorectal and breast carcinomas in her sister. Physical examination showed a woman in pain, who required a walker. She had generalized tenderness over the lumbosacral spine and the right sacroiliac joint. Spine movements were restricted and painful, and lateral flexion and rotations elicited back pain radiating to the right gluteal region. The passive straight-leg-raise maneuver was positive at 20 with sciatic stretch signs on the right side. Right hip rotation elicited pain in the right groin region. Pelvic compression-distraction and Gaenslen’s tests were positive on both sides but worse on the right. The right extensor hallucis longus was weak (4/5), but there was no objective sensory loss. Knee reflexes were present bilaterally (2+), but ankle reflexes were absent. Anal reflex and tone were normal. The distal vascular examination was normal. Her laboratory workup, including CA 19–9 and CA 15–3 (Fujirebio Diagnostics, Inc, Malvern PA), carcinoembryonic antigen, lactate dehydrogenase, protein levels, parathyroid hormone, serum and urine electrophoresis, immunoglobulins, and calcium and phosphorus levels, were normal except for raised alkaline phosphatase of 164 IU/L (normal, 33–130 IU/L) and erythrocyte sedimentation rate of 32 mm/hour (normal, up to 20 mm/hour). A dual-energy xray absorptiometry scan of the hip obtained 6 months previously showed a bone mineral density of 0.6 g/cm with a T-score of -3.6 and a Z-score of -2.5 below the respective standard deviations. Because of previously inconclusive biopsy results and unclear diagnosis, radiographs (Fig. 1), CT scan (Fig. 2), Each author certifies that he has no commercial associations (eg, consultancies, stick ownership, equity interest, patent/licensing arrangement, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his institution has approved the reporting of this case report, that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained.