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Worsening low back pain

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Our patient attributed his back pain to a recent fall, but his lab work and a sagittal CT pointed us in another direction.



A 44-year-old African American man went to his primary care provider complaining of 5/10 dull lower back pain, which he attributed to a recent fall. He reported no radiation of the pain, lower extremity weakness or numbness, or any bowel/ bladder incontinence. Further review of systems and past medical history was unremarkable. He was initially treated with nonsteroidal anti-inflammatory agents and physical therapy. Approximately 2 months later he returned with similar persistent lower back pain complaints; an opiate was added to his pain control regimen. The following week he went to the emergency department (ED), where he reported worsening pain.

In the ED, he was afebrile with normal vital signs. He had a benign musculoskeletal and abdominal exam, and his neurological exam was without any focal deficits. Blood tests revealed a hemoglobin level of 9.8 g/dL with a hematocrit of 27.9%, serum blood urea nitrogen/creatinine ratio of 143/11.0 mg/dL, potassium of 6.5 mmol/L, calcium of 11.8 mg/dL, and phosphorus of 8.5 mg/dL. Urine protein was elevated at 88 mg/dL.

A stat CT of the patient’s abdomen and pelvis revealed no signs of obstructive uropathy to explain his acute renal failure. A sagittal CT reconstruction in bone windows of the initial ED radiological workup was revealing (FIGURE 1).

Sagittal CT reconstruction of thoracolumbar spine

This CT reconstruction in bone windows revealed multiple lucent foci throughout the osseous structures, with an anterior compression deformity of the L2 vertebral body.

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