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

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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 role of factor V Leiden (FVL) mutation in arterial thrombosis is questionable. Previous reports demonstrate a risk for venous thrombosis 7 to 10 times higher with heterozygous FVL mutation and 100 times higher with homozygous mutation, with a less established role in arterial thrombosis.⁷ A retrospective Turkish study compared the incidence of FVL mutation in patients with arterial thrombosis vs healthy subjects; incidence was significantly higher in female patients than female controls (37.5% vs. 2%).⁷ A meta-analysis of published studies showed an association between arterial ischemic events and FVL mutation to be modest, with an odds ratio of 1.21 (95% CI, 0.99-1.49).⁸

The majority of spinal strokes are due to spontaneous occlusion of the vessels with no identifiable cause.

In contrast, a 3.4-year longitudinal health study of patients ages 65 and older found no significant difference in the occurrence of myocardial infarction, transient ischemic attack, stroke, or angina for more than 5000 patients with heterozygous FVL mutation compared to fewer than 500 controls.⁹ The case patient’s clinical course did not fit a thrombotic clinical picture.

Evaluating for “red flags” is crucial in any case of low back pain to exclude serious pathologies. Red flag symptoms include signs of myelopathy, signs of infection, history of trauma with focal tenderness to palpation, and steroid or anticoagulant use (to rule out medication adverse effects).¹⁰ Our patient lacked these classical signs, but she did have subjective pain out of proportion to the clinical exam findings.

Of note: The above red flags for low back pain are all based on expert opinion,¹¹ and the positive predictive value of a red flag is always low because of the low prevalence of serious spinal pathologies.¹²

Striking a proper balance. This case emphasizes the necessity to keep uncommon causes—such as nontraumatic spinal stroke, which has a prevalence of about 5% to 8% of all acute myelopathies—in the differential diagnosis.³

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