Case Diagnosis: Work-up included an elevated PSA and a biopsy of the lesion, which revealed metastatic prostate adenocarcinoma involving the lumbar spine. The patient underwent L2-L3, L3-L4, and L4-L5 TESI with almost complete resolution of back pain. He remains pain-free now several months later and is completing systemic chemotherapy.
Case Description: A 53-year-old male with CAD, TBI, and PTSD presented with six weeks of severe low back pain, characterized initially by a "pop" while walking, followed by anterior thigh burning pain, groin numbness, and left leg weakness. He initially presented to the ED, where a CT Lumbar Spine revealed multilevel degenerative changes. He was discharged home with a muscle relaxer. He re-presented to the ED the next day. With concern for possible spinal cord involvement due to the groin numbness, a MRI Lumbar Spine was performed, which showed multilevel stenosis and a 16 mm L4 vertebral body lesion suspicious for metastasis. He was found to have significant urinary retention during his hospitalization.
Discussions: Prostate cancer most commonly metastasizes to bone, particularly the spine, and may present with neurological symptoms or refractory back pain. Because back pain is almost ubiquitous in men over 50, malignancy can be overlooked, especially when initial imaging shows only expected degenerative changes. Including metastatic prostate cancer in the differential and checking a MRI of the spine or even a PSA when suspicion is even low-to-moderate can expedite diagnosis, prevent neurologic compromise, and guide timely oncologic treatment.
Conclusions: When men over 50 present with atypical or persistent back pain, clinicians should think beyond degenerative disease. A screening PSA is quick, inexpensive, and may detect prostate cancer before catastrophic spinal involvement. Even when malignancy underlies the pain, physiatrists can still employ interventional procedures to improve function and quality of life while definitive therapy proceeds.
