Unusual case presentation-Back pain

Mr.Manoj Krishna - Spine SurgeonShailesh Hadgaonkar - Spinal

Fellow

65 yr,male ,meets General Surgeon for-

C/o Abdominal pain, back pain Uneasiness Mid back pain+girdle pain

O/E – No Clinical findings. No abdominal or spinal tenderness.

Advice Ultrasound Abdomen X-Ray Abdomen

Report Liver-fatty change, rest normal

First Evaluation

X-ray abdomen- normal

Ultrasound abdomen normal

Referral to Spinal Unit-

(After 10 days) Neurology Assessment Thorough clinical Exam. Investigations-I. MRI-Dorsal+Lumbar SpineII. X-Rays of Spine

Clinical Examination

Points to Right Iliac Crest as area of the pain

Mild tenderness at L5/S1 area On questioning reported some loss of appetite- a red flag

X-Rays –Ap/Lat.

Sagittal Mri-T2 &T1 images

Degenerate L5/S1 Disc and Spondylo-listhesis at this level.

Axials Image Coronal Image

No Neural Compression at L5/S1

X-ray showed-Lytic Listhesis,(Mild)Grade 1, L5 over S1(Can be incidental finding on x - ray with no symptoms)

Hence, the Spinal Surgeon advised for a CT Scan Chest &

Abdomen-

Suspecting something remote- also because of the loss of

apetite .

CT Scan –Tumour of the head of the Pancreas

Confirm Diagnosis Bulky Necrotic Tumoral Mass in the Body of Pancreas(Measuring approx

5.9X3.5cm,engulfing spleenic artery & vein) extending to tail.

Pancreatic Carcinoma.

Take Home Messages Pain can be referred to the spine from abdomen and chest lesions

Loss of appetite was the clue Exercise caution about abnormal MRI findings- they can be incidental in up to 50% of cases.

Need to marry up the clinical and radiological picture.