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The involvement of the central nervous system and vertebrae by low grade non-Hodgkin's lymphoma is rare.1 In a previous “lesson of the month”2 in this journal, it was implied that there is always a bad prognosis for patients with spinal lymphoma; however, milder cases may also occur.
A 71 year old man presented to us in January 2000 with a three month history of severe low back pain affecting mainly the left lumbar area and buttock, radiating to the outer aspect of the left thigh and calf. He did not have bladder symptoms or history of recent falls. On examination, he looked well; there was no lymphadenopathy. He had restricted back movement with tenderness of lower lumbar spinal processes. Straight leg raising test was restricted to 45° bilaterally, and produced lumbar pain. Neurological examination of the legs showed normal tone, power, and coordination. Knee jerks were reduced, ankle jerks were absent, both plantars were down going, and there was no sensory deficit.
He had a past history of epilepsy, which was controlled by phenytoin and phenobarbitone. In 1993 he was admitted with abdominal pain, splenomegaly, and pancytopenia; this was diagnosed as low grade B cell lymphoma and hypersplenism. Splenectomy was performed in 1994, his blood count returned to normal, and repeated full blood counts were stable. In 1995 the patient had a fall and severe back pain. A magnetic resonance imaging (MRI) scan showed collapse of T7 and wedging of T4, with evidence of osteoporosis but no infiltration. Treatment was started with etidronate and calcium.
Investigations showed normal serum biochemistry apart from a mild increase of alkaline phosphatase, which was 242 IU/l (normal 60–220). The total white cell count was 24.7×109/l, differential count showed neutrophils 3.5×109/l (14%), lymphocytes 17×109/l (69%), monocytes 4.0×109/l (16.0%), eosinophils 0.2×109/l (1.0%), basophils 0.0×109/l (0.0%), and occasional atypical lymphocytes were seen in blood film. The erythrocyte sedimentation rate was 4 mm/1st h, a myeloma screen was negative, and prostate specific antigen was normal.
A lumbosacral spine x ray examination showed biconcave L5 with diffuse osteopenia. Abdominal ultrasound confirmed splenectomy, but no enlarged lymph nodes were detected. A bone isotopic scan showed increased focal activity in the upper lumbar spine and lumbosacral junction, which was compatible with osteoporosis and degenerative changes.
An MRI scan showed extensive infiltration involving vertebral bodies and appendages throughout the lumbosacral spine, being most intense at the biconcave L5; the appearance was consistent with lymphoma or myeloma (fig 1).
During his stay in hospital, the patient's pain resolved completely after treatment with non-steroidal anti-inflammatory drugs, analgesics, and physiotherapy. His haematologist started treatment of the patient with chlorambucil 10 mg/day for 10 days to be repeated every three weeks, these cycles to be continued for 12 months.
Eight months after the diagnosis of spinal lymphoma, the patient has remained well and active; his back pain is minimal.
In rheumatology, it is essential to differentiate between malignant disease and the more common causes of back pain. Our patient was in a good physical condition, which is unusual for someone with malignancy, his presentation with low back pain appeared to be a typical case of sciatica, and the pain settled down with conventional treatment. Clinically there was no evidence of recurrence of lymphoma—for example, enlarged lymph nodes, weight loss, or fever. However, because of his age at presentation and significant past history thorough investigations were mandatory.
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