CASE HISTORY: Patient is a 55 years old male that has been suffering from pain in the right side of the lumbosacral region that radiates to the buttock, posterior thigh, and lateral calf. There was no history of trauma, but he experienced initial painful symptoms three months ago, while he was sitting with cell phone in his back pocket. The patient describes pain as an occasional sharp shooting pain, which worsened progressively in intensity and frequency. No changes in the bowel and bladder were reported. However, due to the symptoms, his appetite and sleep were disturbed. The condition also restricted him from performing his activities of daily living, which involves prolong sitting. PHYSICAL EXAM: On palpation tenderness elicited in the right Piriformis and Gluteus Medius. Physical examination identified moderately limited lumbar flexion and extension movements while bilateral lateral flexion movement was maintained for the lumbar spine. A McKenzie evaluation of Mechanical Diagnosis and Therapy (MDT) revealed that his symptoms were significantly reduced with repeated lumbar extension in a prone position. DIFFERENTIAL DIAGNOSES: L5-S1 right posterolateral disc herniation, Piriformis syndrome- Sciatica, Benign Prostate carcinoma, and Malignant Prostate Cancer. TESTS & RESULTS: MRI evaluation revealed multiple lesions across the vertebral bodies of the lumbar spine along with some minor disc bulging in the L4-L5 and L5-S1. Subsequently, as the patient’s condition worsened, with tachycardia, he was admitted to ER and then transfer to in-patient services, where oncological evaluation and biopsy were conducted. Biopsy and oncological evaluation revealed primary prostatic cancer with metastasis to the spine. FINAL DIAGNOSIS: Metastatic Prostate Cancer. DISCUSSION: In the United State, the prevalence of prostate cancer in men is 11%. Between the years 2007 and 2013 there was an increase in the number of incidences of metastatic prostate cancer. From 2004 to 2013 the prevalence of metastatic prostate cancer increased by 92%, in men between the age of 55 to 69 years old. Our patient is 55 years old men, which increased his risk by 30%. However, this was an unusual case as the patient did not present any of the usual symptoms, such as urinary retention, hesitancy, increased frequency, bowel changes, and impotency. The clinical manifestations of pain and tenderness along the sciatic region can be accounted to the neurological innervation of prostate glands by inferior hypogastric plexus, which are responsible for the sensory, parasympathetic, and sympathetic function of the gland. In addition, the prostate cancer had metastasized to the spine, which could have caused the symptoms. OUTCOME OF THE CASE: The patient experienced no relief from Acupuncture and Massage Therapy interventions. Non-steroidal anti-inflammatory drugs and Tylenol provided temporary relief of symptoms. A six-week treatment plan including Mechanical Diagnosis and Therapy (MDT), postural education, home exercises, soft tissue mobilization, joint mobilization, and spinal stabilization were administered, which initially relieved his symptoms significantly. However, as his condition deteriorated the patient was admitted to in-patient where the malignancy was diagnosed, only after biopsy and oncological evaluation. The prostate malignancy in the patient has been metastases to the spine. RETURN TO ACTIVITY AND FURTHER FOLLOW-UP: After the diagnosis, the patient has been admitted to in-patient care services where he is under the surveillance of oncologist and physicians for further palliative care.



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