Interactive Case History

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Interactive Case History
Developed by Bernard M. Abrams, MDVice
Chairman, Medical Education Committee,
pain.com Clinical Professor of Neurology,
University of Missouri School of Medicine
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Introduction

• The patient is a 75-year-old, right-handed, white
  male. His chief complaints are
• Aching pain in the lower back and
• buttocks
• Severe cramping spasms
• Elicitable sensory phenomena (reports
• crawling, cobweb-like feeling in the right,
• lower extremity)

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Overview
About four months ago, the patient noted left hip
pain that often kept him awake nights. He also
reported that he could not lie on his left hip,
but that he had no sore spots on palpation. Over
the next several weeks, he noted pain from the
top of his buttocks to the bottom, as well as
from the midline to both hips. While walking
outside to get his paper each morning, he would
develop severe muscle spasms. Upon sitting, the
spasms would dramatically worsen. He would arch
his back and stretch the muscles in his back to
alleviate the pain. The severe spasms would last
several seconds. Approximately four weeks ago,
he had an MRI and then a lumbar epidural block at
S1 and S2. He reported being pain free for about
two weeks. After this time, he noted the pain
gradually returning. However, whereas the pain
had been most prominent on the left, it was now
more painful on his right side.
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Overview, continued
He received a second lumbar epidural block two
weeks ago at L5-S1, which did not work. In the
interim, he also saw a neurosurgeon. His spasms
were worsening, and now included the right
buttock, both thighs, and the right knee in the
lower quadriceps. The pain has progressed to a
buzzing feeling in the right knee and a crawling
feeling. The patient describes this feeling as if
he has cobwebs from his ankle to knee. The
feeling is more intense in the morning. About a
week and a half ago, he was watching an
electrician install wiring in his attic. His head
was tilted up and back. Suddenly, his legs got
weak and he felt as if he was going to fall down.
He lowered his head and arched his back. Since
then, he has been afraid to look up. He reports
being in constant pain most of the week-- even
while in bed. He reports that the feeling is
worse when he leans over a sink to wash dishes,
as well as when walking out to get the paper. He
cant walk very far, and says he cant lift
anything. To bend over, he instead squats and
comes back up. He has a past history of weakness
in his legs when taking a shower and when looking
up.
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Past Medical History
The patient has had inflammatory tendinitis since
2002, which affects his ribs and wrists. He has
an elevated ANA (1200 range) with no other
findings. He would hurt all over with movement.
On one occasion, he had a joint flare-up of the
metacarpal phalangeal joints of the fingers in
his right hand. Since 2003, he has taken
infliximab every 4- to 6-weeks. Four years ago,
he had pain in the inside of his left ear. The
pain went into his temple, down into his jaw, and
behind his ear. He felt he had shingles without
having a rash. He also has a history of carcinoma
of the prostate a skin carcinoma was removed
from the distal left thigh. He has a 50-year
history of migraine equivalents. Subsequent to
his prostate cancer, he has total erectile
dysfunction. He took Viagra once, but it didnt
work. He isnt interested in trying anything else
for fear of migraine headaches. He also has
bladder problems following prostate implantation
of radioactive seeds. Hes also had three hernia
repairs and surgery to his right shoulder. In
1970, he had Graves disease, and now has
residual eye muscle problems.
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Current Medications Allergies

• Medications
• One baby aspirin daily (discontinued for the
  epidurals)
• Levothyroxine, .125 mg, daily
• Dyazide, 37.5 mg, daily (for eye muscles)
• Prednisone, 1 mg bid (for eye muscles)
• Omeprazole for GERD (he aspirates at night if
  not taken)
• Tamsulosin, .4 mg, daily
• Infliximab, every 4- to 6-weeks
• Allergies
• NSAIDS increase his creatinine, which has lasted
  to the present.
• Cimetidine gave him gynecomastia.
• He cant take pain pills, which make me crazy in
  the head as well as somnolent. Hes taken two
  propoxyphene and two one-half tablets of
  hydrocodone in the past two weeks. Hes sensitive
  to muscle relaxants.

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Exam

• Social History Married Retired Non-smoker
• Height 5 feet 8
• Weight 191 lbs
• Blood pressure 138/82, left 145/78, right
• Pulse 86
• No heart murmurs, carotid or abdominal bruits
  excellent arterial pulses in
• his feet. Severe difficulty lowering himself
  into a chair looks uncomfortable
• doing so.
• HEENT are not remarkable.
• Cranial nerves are normal.
• Full range of neck motion. Hyperextension of
  neck produced weakness in
• the legs.
• Abdomen is obese without organomegaly.
• Extremities show a scar from a carcinoma removal
  on the left thigh, and a
• pigmented lesion on the tibial plateau on the
  left, which was pointed out to
• him.

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Exam, continued

• Motor power is intact.
• Deep tendon reflexes are absent at the biceps,
  2 at the triceps, 1 at the
• right knee jerk, 2 at the left knee jerk. The
  ankle jerks are absent. There is
• no Babinski.
• Sensation is intact except for diminished
  vibration sensation from the right
• knee down to the right foot.
• Gait, station, and tandem walking are intact, as
  are heel and toe walking.
• Examination of his low back revealed no
  tenderness over low back or
• buttocks.
• Straight leg raising signs are normal.
• Please review his four MRIs, and then answer the
  questions related to this case history.

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Midline MRI
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Axial MRI
A
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T2 Axial L3-4 MRI
A
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T2 Axial L4-5 MRI
A
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Question One

• For this patient, the most likely diagnosis is
• Herniated disc
• Arachnoiditis
• Spinal stenosis
• Metastasis to the lumbar spine

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Question Two

• The most atypical feature in this patient is the
• Absence of vascular claudication
• Absence of neurogenic claudication
• Absence of bowel/bladder dysfunction
• Absence of sensory dysfunction

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Question Three

• In the usual presentation of this condition, the
  most likely confusion in diagnosis would be with
• Vascular claudication
• Peripheral neuropathy
• Herniated disc
• Metastatic spine disease

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Question Four

• The chances that an epidural block would be
  successful for this patient are
• 25
• 50
• 75
• 90

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Question Five

• The medication most likely to help this patient
  would be
• Baclofen
• Gabapentin
• Divalproex
• Topiramata

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