Typical profile 6

Age:

• Usually over 50, but the older the patient the greater the risk History of injury:

• Usually insidious onset Site and radiation:

• Localised pain anywhere in lumbar spine

• Radiates into buttocks or legs (if nerve root involved)

Type of pain:

• Boring deep ache, can be referred or radicular, unrelenting continuous pain, getting worse Aggravation:

• Specific activities such as lifting, gardening Relief:

• No response to treatment

Associations:

• Malaise, fatigue, weight loss

• Muscular weakness

Physical examination (significant):

• Flattened lumbar lordosis

• Localised tenderness over vertebrae

• All movements restricted and protective (if advanced)

• Neurologically normal unless roots involved

• More than one root may be involved

• Major neurological signs incompatible with pain level

Diagnosis confirmation:

• Serum alkaline phosphatase

With respect to the neurological features, more than one nerve root may be involved and major neurological signs may be present without severe root pain. The neurological signs will be progressive. If malignant disease is proved and myeloma is excluded a search should be made for the six primary malignancies that metastasise to the spine (Fig 33.12). If the bone is sclerotic consider prostatic secondaries, some breast secondaries or Paget's disease.

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