• HPI: 66 year old man presents with one month complaint of worsening low back pain. He was been in his usual state of health until approximately 1 month ago when he developed back pain abruptly. He describes the pain as midback, very intense, and without radiation to one side or another. He has taken Tylenol and Motrin but with minimal improvement. He denies any leg pain and no bowel or bladder dysfunction. The pain improves with lying down but is exacerbated with ambulation. There is no history of trauma. 

    1. Bladder cancer - surgically treated with continued surveillance for the past 4 years with no evidence of recurrence 
    2. Myocardial infarct (stented x 2) 2 years ago 
    3. Hypertension 

    Family Hx: 
    Father had a number of tobacco related complications including oral cancer and lung cancer from which he died. Mother is healthy. 

    1. Metoprolol 
    2. Aspirin 
    3. Lisinopril 

    Social Hx:He is married. He is a construction worker who does very active work shoveling, digging, and doing other activities. He has 2 children. He has a long history of tobacco abuse (1 1/2 to 2 packs / day) but quit 3 years ago. Alcohol use is rare. No illicit drug use history. 

    Neurologic examination: Strength in bilateral upper and lower extremities is 5/5 in grip, biceps, triceps, deltoid, hip flexor-extensor, knee flexor-extensor, dorsiflexion and plantar flexion. Sensation to light touch is intact throughout. Reflexes are 1 and symmetric throughout. Toes are downgoing toes bilaterally. Rhomberg exam is negative. 

    Question 5 (Below) After discussing the various options with the patient, he requests diagnostic biopsy only. He undergoes stereotactic biopsy by Radiology. Final pathology reveals kappa restricted plasmacytoma. Hematology consult is obtained and a skeletal survey shows no other definite lytic lesions. He is placed in a brace and started on radiation therapy.

    Figure 1. Midline sagittal MRI of the lumbar spine. T2 (left) and T1 (right).

    Figure 2. Para-midline sagittal MRI of the lumbar spine. T2 (left) and T1 (right).

    Figure 3. Para-midline sagittal (left) and axial (right) T1 MRI of the lumbar spine with contrast.

    Figure 4. Axial MRI of T12. T2 (left) and T1 (right).

    Figure 5. Lateral upright lumbar spine plain x-ray.

    1. What is the most likely diagnosis for this lesion?

    2. Would you LP the patient to obtain CSF for tumor markers?

    3. Would you perform additional medical work-up or proceed directly to question 5 below?

    4. What is your next step in management?

    5. You decide to take him to the OR for surgical intervention with an open biopsy, surgical resection, and fusion. What is your approach?

    6. Please add any suggestions or comments regarding this case: 

    patient known case of ca urinary bladder biopsy reveals plasmacytoma .no significant vertebral collapse or cord compression .local dxt will releive the pain.no reconstruction or fixation required. If his pain subsides and lesion resolution proven on follow MRI post RT I WOULD OMIT resection and fusion

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