CASE 31: PAIN IN THE BACK
History
A 75-year-old woman presents to her general practitioner (GP) complaining of severe
back pain. This developed suddenly a week previously after carrying a heavy suitcase at
the airport. The pain is persistent and in her lower back. She has had increasing problems
with back pain over the past 10 years, and her family have commented on how stooped
her posture has become. Her height has reduced by 10 cm over this period. Her past med-
ical history is notable for severe chronic asthma. She takes courses of oral corticosteroids,
and use steroid inhalers on a regular basis. She fell 2 years ago and sustained a Colles’
fracture to her left wrist. She developed the menopause at age 42 years. She smokes 30
cigarettes a day, and drinks four bottles of wine a week.
Examination
She has a thoracic kyphosis. She is tender over the L4 vertebra. She has a moon-face,
abdominal striae and a number of bruises on her arms and thighs. She is not anaemic, and
examination is otherwise unremarkable.
NormalHaemoglobin 11.9 g/dL 11.7–15.7 g/dL
Mean corpuscular volume (MCV) 105 fL 80–99 fL
White cell count 6.2% 109 /L 3.5–11.0% 109 /L
Platelets 358 % 109 /L 150–440% 109 /L
Erythrocyte sedimentation rate (ESR) 8 mm/h !10 mm/h
Sodium 143 mmol/L 135–145 mmol/L
Potassium 4.9 mmol/L 3.5–5.0 mmol/L
Urea 5.9 mmol/L 2.5–6.7 mmol/L
Creatinine 102 &mol/L 70–120&mol/L
Calcium 2.42 mmol/L 2.12–2.65 mmol/L
Phosphate 1.26 mmol/L 0.8–1.45 mmol/L
Alkaline phosphatase 156 IU/L 30–300 IU/LX-ray of the lumbar spine is shown in Fig. 31.1.