1325 - Dual Pathways to Pain: Persistent Low Back Pain in a Postmenopausal Woman with Late-Onset Acromegaly and Degenerative Facet Arthropathy

Case Diagnosis: Persistent chronic low back pain secondary to the combined effects of irreversible acromegalic arthropathy and age-related lumbar facet-mediated degenerative changes in a postmenopausal woman, following successful surgical resection and biochemical remission of a pituitary microadenoma.

Case Description:

A 60-year-old active female with a past medical history of late-onset acromegaly secondary to pituitary adenoma who presented with a 1-year history of worsening low back pain and crepitus, superimposed on a 5–6 year history of spinal symptoms. Pain was aggravated by extension-based activities and disrupted sleep due to nocturnal leg cramps. In January 2025, patient  underwent transsphenoidal resection of a 6mm pituitary microadenoma  with preoperative IGF-1 levels greater than three times the upper limit of normal. Despite normalization of IGF-1, her back pain persisted and progressed. Physical exam revealed mild lumbar stiffness, absent left Achilles reflex, and bilateral L5 web space tingling, with no functional limitations. Imaging demonstrated bilateral facet disease at L4–L5 with left L4 foraminal stenosis and minor dynamic anterolisthesis. Conservative management with a home exercise program was initiated, since the patient remains highly active, otherwise healthy, and prefers to defer medications and injections.

Discussions:

This case highlights the complex interplay between late-onset  acromegalic arthropathy and age-related lumbar spine degeneration as contributors to CLBP. Persistent musculoskeletal symptoms may occur despite biochemical remission of acromegaly after surgery, reflecting irreversible joint and soft tissue changes. Pain specialists should maintain a high index of suspicion for secondary causes of CLBP, particularly in patients with atypical features or poor response to standard therapies. Multidisciplinary, individualized management is essential for optimizing outcomes. 

Conclusions: Late-onset acromegaly can unmask or exacerbate degenerative spine pathology, resulting in persistent and complex pain presentations even after surgical or non-surgical means of biochemical remission. Recognition of this dual etiology is critical for optimal diagnosis and management in pain medicine.