Back pain is a familiar ailment for many, often leading to missed work or visits to the doctor. While typically not a cause for serious concern, it can be quite discomforting. However, in certain cases, persistent back pain may signal a deeper, more serious health issue. It's crucial to recognise when this discomfort could be an indication of something more significant.

What is Back Pain Caused By?

Back pain can stem from various sources, ranging from mild to severe causes. Here are some common causes:

• Injury to Muscles & Ligaments: Strain from repeated heavy lifting or abrupt movements can lead to pain, particularly in individuals with weak back and abdominal muscles.
• Degenerative Joint Disease: Conditions like osteoarthritis, spondylosis, and spinal stenosis often lead to the deterioration of spinal joints and discs, contributing to discomfort and limited mobility.
• Disc Herniation: The discs that cushion the bones of the spine can bulge or rupture, pressing on a nerve and causing pain. Interestingly, not all disc herniations result in pain, and they are sometimes discovered incidentally during scans for other conditions.
• Physical Trauma: Sudden impacts from accidents or even falls can cause acute back injuries that are immediately noticeable and often require medical attention.
• Inflammatory Conditions: Diseases like ankylosing spondylitis cause the spinal bones to fuse, making the spine less flexible and often resulting in aching pain.
• Infections: Certain infections like tuberculosis can affect the spine, leading to significant back pain alongside other systemic symptoms.
• Osteoporosis: This condition weakens bones, making them prone to painful fractures, often in the vertebrae.
• Cancer: Metastasis to the spine from other areas or primary bone cancers like multiple myeloma can manifest as back pain, often signalling more advanced disease.

What Are Some Risk Factors of Back Pain?

As mentioned, back pain is a common ailment that can affect anyone, even kids and teenagers. However, certain factors can increase the likelihood of experiencing this discomfort:

• Age: Generally, back pain becomes more prevalent as we age, starting around the ages of 30 to 40, as the body undergoes natural wear and tear.
• Physical Activity: A sedentary lifestyle or inadequate exercise or physical activity in general can weaken the muscles in the back and abdomen when they become underutilised, contributing to back pain.
• Weight: Carrying excess body weight exerts additional pressure on the spine, heightening the risk of developing back issues.
• Health Conditions: Chronic conditions such as arthritis and certain cancers can affect the spine and contribute to back pain.
• Lifting Techniques: Improper lifting, especially using the back instead of the legs, can easily lead to muscle strains or more severe back injuries.
• Mental Health: Psychological factors, like depression and anxiety, can increase one’s sensitivity to pain. Stress can also tighten the muscles, leading to discomfort.
• Smoking: Smoking not only impairs blood flow to the spinal tissues but also increases the risk of osteoporosis and disk degeneration, which can exacerbate back pain.

How Do I Know if Back Pain is Muscle or More Serious?

When does back pain signify a real threat to your health?

Typically, muscle-related back pain is localised and might intensify with specific movements or postures but often resolves within a few days with rest and basic care.

However, if the back pain persists beyond a couple of weeks, affects your daily activities, or is accompanied by more concerning symptoms like severe numbness, unexplained weight loss, or changes in bladder and bowel functions, it's important to seek medical evaluation. This is because such symptoms could indicate a more serious underlying condition requiring prompt attention.

Types of Back Pain that Could Mean Cancer

Back pain that consistently occurs without a clear cause or does not improve with regular treatments could be an indicator of a more serious condition, including cancer. Such pain often manifests with other notable symptoms that could suggest a need for a comprehensive evaluation:

• Persistent Pain: Unlike typical back aches, cancer-related back pain may not be directly linked to physical activity and can worsen at night or remain constant throughout the day.
• Systemic Symptoms: Accompanying signs may include unexpected weight loss, general fatigue, and changes in bowel habits like blood in the stool or urine, which are especially significant if new or progressively worsening.
• Neurological Changes: Experience of weakness, tingling, or numbness in the limbs could suggest nerve involvement.
• Resistance to Usual Therapy: If back pain persists despite physical therapy or standard pain management, it warrants further investigation.

While not all back pain is indicative of cancer, having these associated symptoms, particularly with a personal history of cancer, should prompt a consultation with a healthcare provider to rule out malignancy and ensure appropriate management.

Types of Cancer that May Cause Back Pain

Upper and lower back pain can significantly diminish a person's quality of life and may be a debilitating symptom of various types of cancer. As such, it’s crucial to understand which cancers commonly cause back pain and recognise their potential signs.

Spinal Tumour

Spinal tumours can develop within the bones of the spine or the surrounding areas, often resulting in significant pain. These tumours may originate in the spine or result from metastasis, where cancer from another area spreads to the spine. Such growths can disrupt the structural integrity of the spine and press on nerves, leading to pain and other neurological symptoms.

Lung Cancer

Lung cancer frequently metastasises to the spine, where it can affect spinal stability and nerve function, exacerbating back pain. Individuals with lung cancer might experience intensified back pain alongside symptoms like persistent fatigue, difficulty breathing, and sometimes, coughing up blood. These signs often point to the cancer-impacting areas beyond the lungs themselves.

Breast Cancer

Although less common, back pain can also be associated with breast cancer, especially when the cancer spreads to the vertebral column. This metastasis can pressure nerves and the spinal cord, causing pain. Such symptoms necessitate thorough examination to manage the pain effectively and address the underlying oncological cause.

Gastrointestinal Tract

Cancers within the gastrointestinal tract, such as those of the stomach, colon, and rectum, can manifest as back pain when they spread to the abdominal and back regions. This pain often accompanies other critical symptoms like drastic weight loss or the presence of blood in the stool, signalling advanced disease.

Blood and Tissue

Haematological cancers like multiple myeloma, lymphoma, and melanoma are known to cause back pain due to their direct impact on the bone marrow and bones. Myeloma, in particular, can lead to bone weakening and fractures, which contribute significantly to discomfort and mobility issues.

Other Cancer Types 

Various other cancers, including those of the ovarian, kidney, thyroid, and prostate, might cause back pain as they progress and exert effects on the spine or surrounding tissues. Each type can present with unique symptoms but commonly includes persistent, unexplained back pain as a potential indicator.

A Case Study of Unexpected Diagnosis: Mr. G's Journey

I recall one such patient with severe back pain whom I was asked to see in the middle of the night several years ago. The young man lay sprawled across the hospital bed when I entered the room. One side of his face twitched, pulling his expression into a lopsided frown and then into a grimace of pain.

Mr G, a 35-year-old, had been healthy until a few months earlier when he first noticed a throbbing lower back pain. He initially attributed the back pain to his regular tennis sessions and did not pay much attention to it. As the weeks went by, Mr G started noticing the back pain becoming more severe and frequent. He consulted his family physician, who told him it was likely related to a “muscle” injury from his regular tennis games and prescribed him painkillers. Although the painkillers did provide temporary respite, he continued to have persistent symptoms over the course of the next few weeks. In that period of time, he had seen three other doctors who prescribed him with stronger painkillers and he even consulted a chiropractor, but to no avail.

Mr G was eventually referred to an orthopaedic specialist as the pain became more severe and he was also experiencing numbness in both legs. He was immediately sent to have a magnetic resonance imaging (MRI) of the lumbar spine.

Soon afterwards, he received a call from his doctor, who asked to see him right away. The MRI scans revealed multiple bony lesions and a fracture in one of the vertebral bodies, which was compressing his spinal cord.

His doctor explained to him that he had to be admitted to the hospital and would require surgery to alleviate the compression of his spinal cord. It was that same night that I was called in to see him prior to his surgery. Thankfully, his surgery went smoothly with no complications. The histology results from his surgery confirmed that he had multiple myeloma.

What is Multiple Myeloma? 

Multiple myeloma is a cancer that arises from plasma cells, a type of white blood cell that is produced in the bone marrow. The main function of normal plasma cells is to produce antibodies, also called immunoglobulins, to help fight against infections.

However, in myeloma, these abnormal plasma cells produce non-functioning antibodies, called paraproteins, which build up over time in the blood and urine. It is through the measurement of these paraproteins that myeloma is diagnosed and monitored.

It is not clear what causes myeloma. However, there are some known risk factors associated with multiple myeloma, such as elderly age, male gender, black ethnicity and a history of monoclonal gammopathy of undetermined significance (MGUS).

Why Does Multiple Myeloma Cause Bone Pain?

As the cells of origin for myeloma are from the aberrant plasma cells in the bone marrow, it can, therefore, affect any bones in the body.

The symptoms of multiple myeloma can be divided into those associated with disease in the affected bone and bone marrow, like bone pain, vertebral fractures, anaemia, elevated calcium levels and, in severe cases, compression on the spinal cord, as seen in my patient. The other group of symptoms are related to the accumulation of paraproteins in the blood and urine, leading to kidney damage and an increased risk of infections.

What Does Myeloma Back Pain Feel Like?

Now, what does myeloma or even cancerous back pain feel like, and does the myeloma pain come and go?

Typically, this pain affects the spine, ribs, or hips and is described as a constant, dull ache that can intensify with any movement. This discomfort may not subside with rest, distinguishing it from ordinary muscle-related back pain.

But, of course, the symptoms of end-stage multiple myeloma will vary. For instance, in late-stage multiple myeloma, symptoms can manifest as nausea, bone pain in the back or ribs, easy bruising or bleeding, fatigue, fever, frequent and difficult-to-treat infections, significant weight loss, loss of appetite, and weakness in the extremities.

How is Multiple Myeloma Diagnosed? 

Detecting multiple myeloma often begins incidentally during routine blood tests for unrelated conditions, or it may start with an investigation into specific symptoms suggestive of this type of cancer.

• Blood Tests: These are crucial as they can reveal abnormal proteins, known as M proteins or beta-2-microglobulin, produced by myeloma cells, which help in assessing the disease's progression. Comprehensive blood panels also check kidney function, calcium levels, and complete blood counts to understand overall health and organ function.
• Urine Tests: Myeloma proteins, called Bence Jones proteins, can be identified through urine testing, providing another method for detecting myeloma.
• Bone Marrow Tests: To confirm the diagnosis, bone marrow samples are collected through biopsy and aspiration, usually from the hip bone. These samples are then analysed in a lab to detect myeloma cells and to perform genetic tests, which helps in understanding specific genetic abnormalities in myeloma cells.
• Imaging Tests: Imaging tests like X-rays, MRI scans, and CT /PET scans are employed to visualise bone abnormalities and areas affected by myeloma. These imaging tools are essential for mapping the extent of bone involvement and disease spread.

Routine Diagnostics 

Laboratory Tests

• Full blood count
• Creatinine, electrolytes, calcium, albumin
• Beta-2 microglobulin
• Serum & urine protein electrophoresis (SPEP & UPEP)
• Serum & urine immunofixation electrophoresis
• Serum & urine free light chain assay

Bone Marrow Biopsy

• Aspirate
• Trephine
• Flow Cytometry
• Cytogenetics/ FISH

Imaging

• PET/CT scan or Skeletal survey
• MRI for suspected vertebral compression

What Are the Treatment Options for Multiple Myeloma?

Multiple myeloma may not always present symptoms immediately; this stage is often referred to as smoldering multiple myeloma. In such cases, immediate treatment might not be necessary. However, active monitoring through regular medical check-ups is crucial to detect any progression.

When symptoms do manifest, various treatment strategies to consider include:

• Targeted Therapy: Utilises drugs designed to block specific molecular pathways essential for cancer cell growth and survival, effectively causing the cells to die off.
• Immunotherapy: Boosts the immune system's ability to recognise and destroy cancer cells, which typically evade immune detection.
• CAR-T Cell Therapy: Involves modifying a patient's T-cells to better recognise and attack cancer cells, providing a targeted response against the disease.
• Chemotherapy: Employs cytotoxic drugs that interfere with cancer cells' ability to grow and divide.
• Corticosteroids: Used to reduce inflammation and act directly against myeloma cells.
• Bone Marrow Transplant: Also known as a stem cell transplant, it replaces bone marrow that is diseased with healthy bone marrow.
• Radiation Therapy: Targets and kills cancer cells or shrinks tumours using high-energy radiation, which is beneficial in controlling painful lesions or masses.

Navigating Multiple Myeloma

In the journey through multiple myeloma, accessing specialised care is crucial. At OncoCare, our cancer specialists are committed to providing updated and thorough care plans tailored to each patient’s specific needs. If you or someone you know is dealing with symptoms suggestive of multiple myeloma, reach out to OncoCare for guidance and compassionate care at every step.

 

“Expert knowledge means better care for cancer”

 

Written by:

Dr Kevin Tay
MBBS (Singapore)
ABIM Int. Med (USA)
ABIM Med Onc(USA)
FAMS (Medical Oncology)