Disclosures: Stephanie E. DeLuca, MD, MS: No financial relationships or conflicts of interest

Case Diagnosis: Initial presentation of pancreatic adenocarcinoma with acute on chronic back pain referred from pancreatic mass without spine metastases.

Case Description or Program Description: A 54-year-old man presented with a 4-month exacerbation of chronic lower-thoracic, upper-lumbar back pain. Pain was constant, sharp radiating to chest and right axilla, exacerbated by standing/sitting. Denied weakness, paresthesias, bowel/bladder dysfunction, saddle anesthesia, weight loss, and fevers/chills. Treatment included PT, oral medications, and TENs unit. MRI thoracic/lumbar spine 3 months prior showed L4-5 degenerative disc disease with partial L4-5 disc protrusion. The patient appeared ill with taut bands at lower thoracic/upper lumbar paraspinals, no bony abnormalities, full/nonprovocative thoracic/lumbar spine range of motion, and intact neurologic examination.

Setting: Outpatient spine clinic.

Assessment/Results: Due to concern for an inflammatory process, labs were ordered. An elevated CRP level prompted repeat MRI thoracic/lumbar spine, revealing right-sided mass at T5 level. CT chest/abdomen demonstrated pancreatic mass, confirmed on biopsy as pancreatic adenocarcinoma.

Discussion (relevance): Pancreatic adenocarcinoma classically presents with jaundice, weight loss, abdominal pain, nausea/vomiting, and anorexia. While patients may present with referred pain, it is uncommon to solely present with back pain on initial presentation. Even though imaging and biopsy are the most important diagnostic tools, certain tumor and inflammatory markers are commonly performed. Recent evidence demonstrates a significant association between an elevated CRP and poor prognosis in pancreatic adenocarcinoma. This case illustrates the importance of a broad differential when evaluating patients with atypical back pain. In such cases, it can be useful to order routine blood tests, including inflammatory markers, to guide management.

Conclusions: It is uncommon for pancreatic cancer to initially present with only back pain. Such cases can result in delayed diagnosis. This case demonstrates that in patients with atypical back pain, it can be useful to obtain routine blood tests, specifically inflammatory markers including CRP, before pursuing advanced imaging. Such markers may also be useful prognostic indicators.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/elevated-c-reactive-protein-level-in-a-patient-with-atypical-back-pain-an-initial-presentation-of-pancreatic-adenocarcinoma-a-case-report/