History

March 2022

A 37-year-old software engineer presents to his general practitioner with lower back pain that begins shortly after New Year’s Eve 2021. The patient reports that the pain starts after lifting a heavy suitcase for his mother. Initially, he tries stretching and applying heat, but this does not improve the pain, which he rates as four out of ten. About three weeks later, he seeks advice from a pharmacist and starts taking ibuprofen 400 mg. The medication helps at first, and he takes it intermittently. Several weeks later, however, the pain begins radiating to the left thoracic region. Although he then takes ibuprofen regularly (3 x 400 mg per day), the pain continues to worsen. In the last five days, he notices a slight numbness over his hip when sleeping on his side, which makes him worry and leads him to consult his physician. At this point, he rates the pain as six out of ten.

The engineer’s last general check-up is two years earlier and is unremarkable. He has received all recommended vaccinations and follows an overall healthy diet. He has no chronic medical conditions and takes no long-term medication.

Status at presentation

Thoracic and lumbar spine are tender, range of motion is normal, sensitivity is reduced over the left lateral thigh, and the patellar shift ratio (PSR) appears questionably reduced in both knees. The patient is afebrile, with no clinical signs of infection. Lung auscultation is clear, and the abdomen is non-tender. He reports no night sweats or unintentional weight loss.

Blood pressure is 121/78 mmHg, pulse 64 bpm, height 182 cm, weight 73 kg, BMI 22 kg/m².

Considering these findings, the physician orders an MRI of the thoracic and lumbar spine, which is performed the following day.

The MRI reveals lesions in D8-D11, L3 and L4, the latter with suspicion of a stable fracture. All lesions appear suspicious for metastases (Figure 1). The software engineer is subsequently referred to the oncology department for further management.

Figure 1: Spinal lesions in the thoracic spine identified on the initial MRI (March 2022).