PATIENT 1

A 65 year old man was admitted with a one month history of increasingly severe left sided sciatica. He had one previous episode of low back pain 40 years earlier. Four months before admission, a left inguinal hernia was repaired and following this he had complained of pain in the left testicle. His pain had rapidly increased day and night despite chiropractic treatment, and he complained of anorexia and weight loss, but no night sweats.

On examination he appeared unwell and was in very severe pain, although with no focal spinal tenderness. All movements of the lumbar spine were reduced, with straight leg raising reduced on the left to 60°, with a positive sciatic stretch test. The left ankle jerk was absent. There were no abnormalities in the heart, lungs or abdomen.

Blood tests showed a high erythrocyte sedimentation rate (ESR) of 91 mm 1st h with an anaemia of chronic disease. C reactive protein (CRP) was high at 70 mg/l, liver function tests, including alkaline phosphatase, and urea and electrolytes were normal, as were calcium and prostate specific antigen. Urine analysis on dipstick testing was normal. Although initial radiographs of the lumbar spine were unremarkable, apart from disc space narrowing only at level L5/S1, magnetic resonance imaging of the lumbar spine showed extensive abnormal signal within L5/S1 consistent with a malignancy (fig 1) and abnormal tissue surrounding the left L5 and S1 nerve roots. …