Differential Diagnosis

Case #1 History Cagan Laughlin59 year old white male presents to your office with severe back pain slightly bent over while walking.6’ 0”, 145lbsPt states while on vacation In Florida he was riding the roller coaster “THE SUBLUXATOR” for the 3rd time that day; during a high centrifugal force turn heard and felt a “popping noise” in his lower back. As he heard the noise he felt a loss of height and as if “he was slightly leaning to the right.” Pt has severe pain in lower back @L3/L4 with pain in right lateral thigh. QVAS 8/10.Pt “thinks something bad has happened but not sure exactly what”.

History Cont’d

Pt had no known serious childhood diseases. No difficulty urinating.

Pt does not smoke, sedentary lifestyle

Drinks 4 sodas per week.

Pt states his diet is “good” and does not eat fast food often.

During Hx reveals refined white carbohydrates consumed at least once daily in the form of pasta and rice.

History

Patient loves bologna, salami and other cold cut red meats which he consumes 3-4x/ week.

Worried about job security and is under a lot of stress.

Differentials….

?

Differentials

- Trauma- induced injury from roller coaster

- Fracture- “popping” noise followed by pain in lower back.

- Low Back Strain/Sprain- induced injury

- Osteomalacia- bone softening, leading to other complications.

- Complications of osteoporosis- Disc herniation

Exam findings

Limited all ROM’s in lumbar spine with most notable decrease in R lateral flexion and extension. Unable to tolerate standing upright or sitting for too long. +SLR local back pain. +Kemp for local pain only, mostly to the right.

BP: 132/82 Temp: 98.7

+ Jump sign to non-noxious stimuli when palpating over L4/L5 area.

Generalized muscle guarding and splinting by lumbar paraspinals and abdominals.

Next step?

Next Case

Case # 2 Benjamin Utash

Pt. present to your office with mid thoracic pain around T6-T8Pt. states that was enjoying last Saturday with some very close friends and when he bend forward to … pick up the charcoal to put it on the BBQ he felt a sharp pain on the mentioned area.Pt. took OTC for pain until this morning that the pain is getting worse and decided to look for help.

Can we help this Pt.?

Hx. 54 yoa, non smoker, married, no kids, Retired from local postal office and Chip N’ Dale Dancer on Wednesday nights.

Eats healthy, no alcohol, no drugs, no sodas, no coffee.

QVAS 9/10

Diff/Diag.

- Fracture- Low Back Strain/Sprain- Osteomalacia - Osteoporosis- Disc herniation- Facet Sy.- Disc bulge

Partial P.E.

5’10” 185lbs

Temporal pulse-Bilateral and Symmetrical

Bald

No facial hair

Normal skin texture

Cervical ROM-WNL

Thoracic ROM- Can’t perform any.

Lumbar ROM- Flex 15* others WNL

+tuning fork test over T7 SP

+valsalva

Pt. cant perform any other ortho test

OHHHH. Nooooooo Now what????????

Tools

X-Rays

Lab

DEXA

Case # 3 Dulvesa Stasiak

Dulvesa Cont’d

Age : 21yoa, 3rd year university student Chief Complaint: Low Back Pain Hx of Chief:Duvi was referred to us by the college nurse due to a fall on her back after she faint during Zumba class. The pain is sharp, constant, localized and getting worse”.

Provisional Dx:

1. Anorexia nervosa

2. Osteoporosis

3. Compression fracture

4. Lumbar sprain/strain

5. Osteomalacia

Past Hx/ Trauma Hx:

1. Previous hx of 5th metatarsal Fx

2. 3 years of untreated anorexia.

3. Amenorrhea

4. Loss of hair

5. Fatigue

6. Constipation

Physical exam:

Weight: 85 lbsHeight: 5’2”HyperkyphosisBrittle hair and nailsDry skinTeeth : enamel erosionCervical ROM= WNLLumbar ROM= can’t perform anyBP= 80/50Resp= 9

Cont…

Ortho: Tuning fork test: +

Valsalva=+

Unable to perform any other test due to severe pain.

Moderate pain upon digital palpation on lumbar paraspinals.

Update Provisional Dx:

1. Compression Fracture2. Osteopenia/ Osteoporosis3. Anorexia4. Amenorrhea5. Kidney stones6. Constipation7. Lumbar sprain /strain8. Underweight9. Hyperkyphosis10. Motor weakness11. Disc herniation

Case # 1 conclusion, what did Cagan Laughlin have? And why?

ImagingYou immediately send out for imaging: Plain film x-ray reveals compression fracture at L3 with noted thinning of the cortices and changed trabecular patterns.

Up to ___% bone loss to see on plain film x-ray.

DEXA

Gold Standard Osteoporsis: Dual-Energy X-ray Absorbtiometry.Other Imaging: Quantitative CT and Ultrasonagraphy, Single Photon Absorbtiometry.Reveals: Standard Deviation of -2.6 at L3, -2.0 at L4, -2.2 at L5.

DXA Criteria According to W.H.O.

Diagnosis of compression fracture complicated by osteoporosis confirmed

Problems with DXA

Doesn’t recognize recency of bone loss

Doesn’t recognize rate of bone loss

Cannot measure effect of current protocol

Typically high cost. (How much at Parker?)

NTX Osteomark Assay

Measures Cross-Linked N-Teleopeptide Type I Collagen specific to bone.

Measured in urine

Assess current rate of bone loss.

Assess effectiveness of protocol

Low cost. $55

Other Lab

Urinary Hydroxyproline

Alkaline Phosphatase

Calcium/Phosphorous

Definitive Diagnosis

Fracture due to complications brought on by osteoporosis.

Poor diet, high protein, phosphorous from soda, high refined carbohydrates.

Case # 2 conclusion, Wassup wit Ben Utash? Y Porque?

X-Rays

Dexa revisited…

With an osteoporotic patient what should we see as the result?

DEXA

-2.7 at T7 CBC - WNL

Lab.

OHHHHH Nooooooo.. Now What?

Chemistry

LH – H

GnRH – H

Low Testosterone

OHHHHH Nooooo. Now what?

Complete P.E.

After a Complete P.E. only this was noted.

Definitive Diagnosis

HypogonadismWT…

Testosterone

When dealing with the prevention of osteoporosis, testosterone deficiency in males strangely enough is also associated with estrogen deficiency. In males, testosterone, which is in a much larger amount than in women, is converted to estrogen. So, after testosterone is in the blood, it gets converted to estrogen. Believe it or not, estrogen is extremely important in men in preserving bone, just as it is in women.

Estrogen

It is interesting to note that estrogen is necessary for bone strength in men. This has been clearly demonstrated in men who lack aromatase, the enzyme which converts testosterone into estrogen.

Risk Factors

Increased age Decreased weight Low activity level Poor dietary calcium intake SmokingHistory of alcoholism Chronic bronchitis Gastric resectionThyroidectomyHemiplegiaParkinsonismDementiaBlindness Low testosterone Low estradiol SSRI use Selective Serotonin Reuptake Inhibitor “Depression Tx”

Some of these risks are due to gait and balance problems and not bone density. Larger studies are ongoing to more clearly define which risks are more important and which are independent.

Prevention

Basic prevention is the same in men as in women. Both men and women need adequate calcium, vitamin D, exercise, optimal weight, and should not smoke cigarettes.

Case #3 conclusion, Duvelsa Stasiak…why she look so skinny?

Diagnostic Imaging

A-P lateral lumbar view:

Shows L4-L5 acute wedging fracture with approximately 30-40% loss of

anterior vertebral body height.

General bone density is diminished.

The soft tissue do not show any abnormal masses or calcification.

Labs

• Glucose- decreased

• Dexa- -2.5

• CBC= Hbg low

• SMAC 21= Low Lytes

• Estrogen= low

Definitive Dx:

• Osteoporosis

• Compression Fracture

• Anorexia nervosa

What do Cagan, Benjamin and Duvelsa have in common?

Osteoperosis

Osteoperosis• Decrease in general bone density

resulting in architectural changes.

• Creates fragile bone which may lead to increased risk of fracture

• An imbalance between formation and resorption

Who’s at risk?1) Females

2) Seniors

3) Family Hx of

4) Post menopause

5) Amenorrhea

6) Anorexia nervosa or bulimia

7) Diet low in Calcium

8) Thin and or Small frame

9) Use of meds: Steroids and anticonvulsants

10) Low testosterone in men

11) Inactive lifestyle

12) Cigarette smoking

13) Excessive use of alcohol

Types of Osteoperosis

• Type I: postmenopausal resulting from gonadal deficiency

• Type II: senile due to decreased formation of bone and production of 1,25 (OH)2 D3 occurring late in life

• Type III: secondary due to medications causing bone loss

Differentials

• Cushing's Syndrome

• Anticonvulsant use• Intestinal

malabsorption• Chronic heparin

use• Hyperparathyroid

• Immobilization• Glucocorticoid use• RA• Multiple Myeloma• Osteomalacia

References

• Bone Pathology XR 4424

• Conditions Manual 3rd Edition

• Differential Diagnosis for the Chiropractor; Souza.

• www.emedicine.com

• www.medscape.com