Clinical Chiropractic (2006) 9, 109—111
intl.elsevierhealth.com/journals/clch
CASE CHALLENGE
Geriatric low back pain: Presentation
Martin Young a, Michelle A Wessely b,*
a
Yeovil Chiropractic Clinic, 142, Sherborne Road, Yeovil, Somerset BA21 4HQ, UK
b
Department of Radiology, Institut Franco-Europeen de Chiropratique (IFEC),
24 Boulevard Paul Vaillant Couturier, 94200 Ivry Sur Seine, France
Received 25 May 2006; accepted 31 May 2006
History
A chiropractic patient contacted her local clinic
requesting a house visit for her 79-year-old husband,
a retired engineer who had been confined to his bed
for the previous 5 weeks with acute, severe low back
pain. On attending, the patient was in a makeshift,
ground floor bed, being unable to climb the stairs to
his usual bedroom. He was able to rise to his feet,
but was only able to stand if supported and found
any movement unbearably painful.
Mr D had an extensive orthopaedic surgical his-
tory commencing in 1963 when he was involved in a
road traffic accident in which he was thrown through
the windscreen of a car, suffering a broken nose and
extensive soft tissue trauma to the knees. Although
he reported no history of back pain prior to 1993, in
that year he attended an orthopaedic surgeon
reporting a 6-month history of back pain, diagnosed
as degenerative spinal stenosis. He underwent a
laminectomy and surgical fusion with a Harrington
Plate; unfortunately, the right sciatic nerve was
severed during this procedure.
In 1998, the same surgeon fitted a left knee
prosthesis; in 2000, he had a partial colonectomy
to remove a cancerous growth; the following year,
* Corresponding author. Tel.: +33 1 4515 8918;
fax: +33 1 4515 8911.
E-mail addresses: clinchiro@elsevier.com (M. Young),
mwessely@ifec.net (M.A. Wessely).
1479-2354/$32.00 # 2006 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.clch.2006.05.001
his orthopaedic surgeon fitted a right hip prosthesis.
In 2003, he was operated upon again, this time
replacing the right knee (Fig. 1).
Unfortunately, he experienced complications
with this surgery, developing a methicillin resistant
Staphylococcus aureus (MRSA) infection at the sur-
gical site. Despite extensive treatment, the infec-
tion persisted and he re-entered hospital in October
2005 to surgically remove a nidus of infection in his
tibia. He subsequently developed a deep vein
thrombosis, which resulted in a pulmonary embo-
lism. During his extended stay in hospital, he began
complaining of low back pain; this was aggravated
when he suffered a fall approximately seven weeks
prior to his house call, whilst still an in-patient. He
had been suffering back pain ever since, although
his knee appeared to be healing satisfactorily. His
general practitioner had prescribed analgesia and
bed-rest.
Clinical findings
On examination, neurological deficit was noted, con-
sistent with the iatrogenic neuropathy noted above.
Lumbar range of motion was universally painful and
restricted. The psoas muscles were both weak, par-
ticularly on the left (3/5), and gravitational resis-
tance recreated the mid-lumbar element of the low
back pain. Extensive guarding was noted in the erec-
tor spinae, quadratus lumborum, sacrospinalis and
110 M. Young, M.A. Wessely

Figure 2 Postero-anterior weight-bearing lumbo-pelvic

radiograph.
Figure 1 Lateral radiograph of the right knee.

Figure 3 Lateral weight-bearing lumbo-sacral radiograph (a) with spot view (b).
Geriatric low back pain: Presentation
glutei bilaterally. Straight leg raise could not be
performed on the right owing to the recent surgery,
but was normal on the left. The patient was afebrile;
pulse and blood pressure were unremarkable.
 What is your differential diagnosis at this stage?
 Are there any further tests you would wish to
perform?
111
 What is your immediate management plan for this
patient?
The patient was treated palliatively and arrange-
ments were made for early radiological examination
(Figs. 2, 3a and b).