Sharp lower back pain • left-side paraspinal tenderness • anterior thigh sensory loss • Dx?

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Case Reports

Sharp lower back pain • left-side paraspinal tenderness • anterior thigh sensory loss • Dx?

J Fam Pract. 2020 April;69(3):150-153

By

Srikanth Nithyanandam, MBBS, MS

Kyle Smoot, MD, CAQ

Kevin Schleich, PharmD

Tyler Slayman, MD

► Acute-onset, sharp nonradiating lower back pain
► Left-side paraspinal tenderness
► Anterior thigh sensory loss

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References

1. Romi F, Naess H. Spinal cord infarction in clinical neurology: a review of characteristics and long-term prognosis in comparison to cerebral infarction. Eur Neurol. 2016;76:95-98.

2. Hanson SR, Romi F, Rekand T, et al. Long-term outcome after spinal cord infarctions. Acta Neurol Scand. 2015;131:253-257.

3. Rigney L, Cappelen-Smith C, Sebire D, et al. Nontraumatic spinal cord ischaemic syndrome. J Clin Neurosci. 2015;22:1544-1549.

4. Novy J, Carruzzo A, Maeder P, Bogousslavsky J. Spinal cord ischemia: clinical and imaging patterns, pathogenesis, and outcomes in 27 patients. Arch Neurol. 2006;63:1113-1120.

5. Goldstein LB, Adams R, Alberts MJ, et al; American Heart Association; American Stroke Association Stroke Council. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2006;113:e873-e923.

6. Mateen FJ, Monrad PA, Hunderfund AN, et al. Clinically suspected fibrocartilaginous embolism: clinical characteristics, treatments, and outcomes. Eur J Neurol. 2011;18:218-225.

7. Ozmen F, Ozmen MM, Ozalp N, et al. The prevalence of factor V (G1691A), MTHFR (C677T) and PT (G20210A) gene mutations in arterial thrombosis. Ulus Travma Acil Cerrahi Derg. 2009;15:113-119.

8. Kim RJ, Becker RC. Association between factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations and events of the arterial circulatory system: a meta-analysis of published studies. Am Heart J. 2003;146:948-957.

9. Cushman M, Rosendaal FR, Psaty BM, et al. Factor V Leiden is not a risk factor for arterial vascular disease in the elderly: results from the Cardiovascular Health Study. Thromb Haemost. 1998;79:912-915.

10. Strudwick K, McPhee M, Bell A, et al. Review article: best practice management of low back pain in the emergency department (part 1 of the musculoskeletal injuries rapid review series). Emerg Med Australas. 2018;30:18-35.

11. Cook CE, George SZ, Reiman MP. Red flag screening for low back pain: nothing to see here, move along: a narrative review. Br J Sports Med. 2018;52:493-496.

12. Grunau GL, Darlow B, Flynn T, et al. Red flags or red herrings? Redefining the role of red flags in low back pain to reduce overimaging. Br J Sports Med. 2018;52:488-489.

13. Lansberg MG, O’Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 suppl):e601S-e636S.

14. Pikija S, Mutzenbach JS, Kunz AB, et al. Delayed hospital presentation and neuroimaging in non-surgical spinal cord infarction. Front Neurol. 2017;8:143.

THE CASE

A 64-year-old woman with a history of late-onset type 1 diabetes mellitus, Hashimoto thyroiditis, and scoliosis presented to the sports medicine clinic with acute-onset, sharp, nonradiating right lower back pain that began when she bent forward to apply lotion. At presentation, she denied fever, chills, numbness, tingling, aggravation of pain with movement, weakness, and incontinence. Her neuromuscular examination was unremarkable except for left-side paraspinal tenderness. She was prescribed cyclobenzaprine for symptomatic relief.

Two days later, she was seen for worsening pain. Her physical exam was unchanged. She was prescribed tramadol and advised to start physical therapy gradually. As the day progressed, however, she developed anterior thigh sensory loss, which gradually extended distally.

The following day, she was brought to the emergency department with severe left-side weakness without urinary incontinence. Her mental status and cranial nerve exams were normal. On examination, strength of the iliopsoas and quadriceps was 1/5 bilaterally, and of the peroneal tendon and gastrocnemius, 3/5 bilaterally. Reflexes of triceps, biceps, knee, and Achilles tendon were symmetric and 3+ with bilateral clonus of the ankle. The Babinski sign was positive bilaterally. The patient had diminished pain sensation bilaterally, extending down from the T11 dermatome (left more than right side) with diminished vibration sensation at the left ankle. Her perianal sensation, bilateral temperature sensation, and cerebellar examination were normal.

Magnetic resonance imaging (MRI) without contrast of the lumbar spine demonstrated ischemia findings corresponding to T12-L1. Degenerative changes from L1-S1 were noted, with multiple osteophytes impinging on the neural foramina without cord compression.

THE DIAGNOSIS

The initial presentation was consistent with mechanical low back pain with signs of anterior spinal artery infarction and medial lemniscus pathway involvement 48 hours after initial presentation. Spinal cord infarction occurs more commonly in women and in the young than does cerebral infarction,¹ with better reemployment rates.^1,2 Similar to other strokes, long-term prognosis is primarily determined by the initial severity of motor impairment, which is linked to long-term immobility and need for bladder catheterization.³

Neurogenic pain developing years after spinal cord infarction is most often observed in anterior spinal artery infarction⁴ without functional limitations.

Initial treatment. Our patient was started on aspirin 325 mg/d and clopidogrel 75 mg/d. Her mean arterial blood pressure was maintained above 80 mm Hg. Computed tomography angiography of the abdomen and pelvis was negative for aortic dissection. Lumbar puncture for cerebrospinal fluid analysis was unremarkable. Results of antineutrophil cytoplasmic antibody testing, antinuclear antibody testing, a hepatitis panel, and an antiphospholipid panel were all negative. The patient was started on IV steroids with a plan for gradual tapering. The neurosurgical team agreed with medical management.

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