Cases corner – 62 years old with back pain

27th January 2021

Mr K, a 62 year old man, attends with persistent upper back pain for the last 3 months. He denies any other symptoms and denies radiation of the pain. On examination, the pain is elicited on firm pressure over the vertebral body.

What would you do next?

  1. Reassure him and offer safety-netting advice if he deteriorates
  2. Request a full blood count, serum calcium and erythrocyte sedimentation rate (ESR)
  3. Request protein electrophoresis
  4. Request serum immunoglobulins
  5. Refer the patient along a 2-week-wait pathway to haematology

This patient is at risk of Myeloma. The most common presentations for myeloma are: symptomatic anaemia (75%), bone disease (70%), hypercalcaemia (30%), and renal failure (25%). Therefore the back pain is concerning for bone disease and so should be investigated further. Back pain is a common presentation within primary care, it is important to recognise what the best way is to exclude sinister pathology. Although many would consider organising x-rays/ plain films of the area of the spine in concern, these are in actual fact very poor at identifying primary disease within the spine. This is not to be confused with when x-rays are used to identify secondary deposits or metastatic disease.

The NICE NG12 Guidelines recommend, in the first instance to conduct a full blood count, serum calcium, and erythrocyte sedimentation rate (ESR).

“Offer a full blood count, blood tests for calcium and plasma viscosity or
erythrocyte sedimentation rate to assess for myeloma in people aged 60 and over with persistent bone pain, particularly back pain, or unexplained fracture”

Within London, the pathways lowers the age to 40 for a patient to be offered these tests.

Protein electrophoresis and serum immunoglobulins are also often considered part of the work up for myeloma. However, as the pathways priorities the most cost effective way to diagnose or exclude the cancer, a full blood count, calcium and ESR are recommended in the first instance as it is very unlikely that a patient would have myeloma should these be normal.