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A young lady who just turned 18-year-old was presented to the clinic complaining of pain in the lumbosacral region (slightly intense at the left side) with referral into the left posterior thigh. She first experienced the acute pain three days ago while pulling the cable out of the swimming pool. 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 could be:
Venous thromboembolism (VTE) refers to a
process of blood coagulation that includes both deep vein thrombosis (DVT) and
pulmonary embolism (PE). It is a common but life-threatening disease with
frequent recurs and severe long-term complications. It accounts for the third most common
vascular disorder after myocardial infarction and stroke, affecting 1 per 1000
persons of African and Asian origin. The
survival rate after VTE is significantly lower, especially for PE, causing
almost 25% of sudden deaths. Nearly 30% of survivors intend to develop VTE
relapses and venous stasis syndrome during the later years of their lives
(within 10-20 years).
Patient presented with acute
musculoskeletal symptoms was later diagnosed with multiple deep vein thrombosis
(DVT). The patient recovered well with anticoagulation therapy and insertion of
a vena cava filter.
Patients’ medical and family history did
not reveal anything. However, the patient’s only medication was birth control
pills.
Based on the physical examination, a
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 orthopaedic examinations were in the normal
limits. A Doppler ultrasound was performed to look for the venous flow, which
was found 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.
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 involving 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. 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, 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.
As learning from this case, it is crucial 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 discolouration 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. General risk factors for VTE are enlisted in Table 1.
Table 1: Risk factors for VTE
|
Potential risk factors |
Moderate risk factors |
Low risk factors |
|
Surgery Hip/knee replacement |
Hospital confinement |
Aging |
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 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 electrocardiography. While the primary treatment
approach aims to prevent further clot extension, PE and minimize the risk of
recurrence.
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.
J Chiropr Med. 2015 Jun; 14(2): 83–89.
Multiple Venous Thromboses Presenting as Mechanical Low Back Pain in an 18-Year-Old Woman
Andrée-Anne Marchand et al.
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