Pain
Casey W. Pierce, MD
PM&R Resident
University of Alabama at Birmingham
Birmingham, Alabama, United States
Lisa K. Humphries, MD
Assistant Professor
University of Alabama Birmingham
Birmingham AL, Alabama, United States
David Salchert, MD
Resident Physician
The University of Alabama at Birmingham
Birmingham, Alabama, United States
Casey W. Pierce, MD
University of Alabama at Birmingham
Birmingham, Alabama, United States
A 68-year-old male with hypertension, HIV, and longstanding low back pain presented multiple times over one year to urgent care and the emergency department for right gluteal pain radiating down the right lower extremity with intermittent numbness. He was repeatedly treated with oral and intramuscular steroids, NSAIDs, and muscle relaxants without imaging. Eventually referred to a PM&R pain clinic, he described years of low back pain with radicular symptoms that had worsened over six months. The only potential red flag was a 20-pound weight loss, attributed to intentional dieting. Lumbar and sacroiliac radiographs revealed patchy sclerotic foci. CT confirmed diffuse sclerotic lesions of the lumbar spine, sacrum, and pelvis. PSA exceeded 1,420 ng/mL, and PET imaging demonstrated widespread osseous metastatic disease. Prostate biopsy confirmed high-grade adenocarcinoma. He began systemic androgen deprivation and chemotherapy, with hematology-oncology assuming pain management.
Discussions:
Low back pain is a leading cause of physician visits, with most cases attributed to benign mechanical etiologies. While red flag criteria guide evaluation, only a prior history of malignancy is strongly predictive for cancer-related back pain. This case shows that metastatic disease can present without classic red flags such as unintentional weight loss, night pain, or insidious onset. Symptom attribution to “sciatica” delayed diagnosis until baseline imaging at a pain clinic revealed metastatic lesions. Early identification of serious spinal pathology through timely imaging in refractory cases may allow patients to start definitive treatment sooner, potentially improving prognosis.
Conclusions: Physiatrists and pain physicians should maintain a broad differential for acute on chronic low back pain. Baseline imaging is warranted when symptoms are refractory to conservative measures, even without traditional red flags. This approach helps avoid missed diagnoses of serious spinal pathology such as metastatic cancer and enables earlier intervention for better outcomes.
