A Case of Multiple Venous Thromboses Presenting as Mechanical Low Back Pain

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SCIENCE
A Case of Multiple Venous Thromboses Presenting as Mechanical Low Back Pain

A young lady who just turned 20 year-old was presented to the clinic complaining of lower back pain (slightly intense at left side) with referral into the left posterior thigh. She first experienced the acute pain about four days ago while playing volleyball, but she stated to be ignorant towards it continued playing. She was an active student and was continuously involved in sports events. Though she never experienced numbness, or weakness in the lower extremities, the pain occasionally radiated downwards below the knee with forward bending of the lumbar spine. The intensity of the pain was severe enough to limit her daily activities.

The most likely diagnosis of this presentation is

  • Low Back Pain

  • Deep Vein Thrombosis

  • Ruptured Baker cyst

  • Hematoma

  • Venous Insufficiency

Introduction

Venous thromboembolism (VTE) refers to a process of blood coagulation that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE).1 It is a common but life threatening disease with frequent recurs and serious long-term complications. 2 It accounts for the third most common vascular disorder after myocardial infarction and stroke,1 affecting 1 per 1000 persons of African and Asian origin.2 Survival rate after VTE is significantly lower, especially for PE causing almost 25% of sudden deaths. Almost 30% of survivors intend to develop VTE relapses and venous stasis syndrome during the later years of their lives (within10-20 years). 2

Examination

Patients’ medical and family history did not reveal any significant evidences of having any underlying cause for these symptoms. Based on the physical examinations, standard lumbar x-ray was undertaken which turned out to be normal. Palpation indicated pain and stiffness of the left piriformis and gluteus medius muscles. Decreased range of motion was found in her thoracolumbar junction and bilateral sacroiliac joints. Neurological and orthopedic examinations were in the normal limits. A Doppler ultrasound was performed to look for the venous flow, which was shown to be reduced in the femoral vein area. While an extensive DVTs affecting the left femoral vein and iliac axis were found during an additional ultrasound examination. Anatomical alterations in the left iliac vein and absence of blood dyscrasias were noted, which may indicate May-Thurner syndrome.

Treatment

The initial symptoms and the questionnaire, allowed making a provisional diagnosis of the acute myofascial syndrome of the left piriformis and gluteus medius muscles. A therapy consisting manipulation of the soft tissues the left gluteus area and the thoracic, lumbar and sacroiliac joints was considered as an initial approach to relieve the pain. Further treatment approach included three chiropractic adjustments over a week, which resulted in a significant improvement pain and the frequency. An anticoagulation therapy was initiated with Heparin and she was advised not to take other medications without consulting. Three days later the discharge, the patient was admitted to emergency care due to a sudden onset of chronic pain in the left iliac area, and she also complained of low back pain with a feeling of heaviness and pain in the left thigh. Following which, a lung scintigraphy revealed hypoperfusion (shock). Further blood examinations showing a reduced platelet level and Heparin-Platelet Factor 4–induced antibodies, confirmed the diagnosis of Heparin induced-thrombocytopenia. The patient was successfully treated with a vena cava filter and Argatroban anticoagulation therapy.

Discussion

As learning from this case, it is important to undertake a detailed medical and family history as well as physical examination when vascular peripheral involvement is suspected. Assessing the potential risk factors and physical examination for discoloration of the skin, edema, limb asymmetry, pulses, and tenderness to palpation should also be considered. Common independent risk factors for VTE include accidental injuries or surgery, hospitalization, melanoma, neurological disease, superficial vein thrombosis, transvenous pacemaker, etc. In women, the use of oral contraceptives, pregnancy and the postnatal period, and hormone therapy may serve as independent risk factors.2 General risk factors for VTE are enlisted in Table 1.

Table 1: Risk factors for VTE2

Potential risk factors

Moderate risk factors

Low risk factors

Surgery
Major accidental injury

Hip/knee replacement

Hospital confinement
History of VTE
Cancer
Central venous catheter
Pacemaker
Paresis
Oral contraceptive/hormone therapy
Thrombophilia

Aging
Pregnancy
Immobility
Superficial vein thrombosis

Although an individual’s tendency to develop VTE at any point of his/her life is about 11%, the risk of developing it significantly increases with age, irrespective of gender. Pulmonary embolism with or without DVT is more severe and has a higher recurrence rate.  Mostly, DVTs tend to affect the lower limbs and become symptomatic on proximal vein involvement. There are no typical signs and symptoms indicating DVTs and moreover, it can also be asymptomatic. However, its classic signs may include inflammation, pain, warmth and reddening. The assessment of patients with possible PE should begin with a chest x-ray and electrocardiograph. While the primary treatment approach aims to prevent further clot extension, PE and minimize the risk of recurrence.3

Learning

Presence of DVTs in low-risk individuals is often ignored or misdiagnosed. Patients presenting with subtle symptoms including acute musculoskeletal symptoms should be suspected DVTs and further extensive diagnosis.

Reference

  1. Naess I.A., Christiansen S.C., Romundstad P., Cannegieter S.C., Rosendaal F.R., Hammerstrom J. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost. 2007;5:692–699.

  2. Heit JA. The epidemiology of venous thromboembolism in the community: implications for prevention and management. J Thromb Thrombolysis. 2006 Feb;21(1):23-9.

  3. Andrée-Anne Marchand, ,⁎ Jean-Alexandre Boucher, and Julie O’Shaughnessy. Multiple Venous Thromboses Presenting as Mechanical Low Back Pain in an 18-Year-Old Woman. J Chiropr Med. 2015 Jun; 14(2): 83–89.

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