Worsening upper back pain that wakes her at night, a 48-year-old: a case to work up

Why back pain that wakes her at night matters

Most back pain is mechanical and settles. Pain that keeps getting worse, wakes the patient at night or sits in the middle of the back is a warning sign for infection, cancer or fracture, and a normal X-ray early on does not rule these out.

What to ask in the history

• Where the pain is, how it has changed, pain at rest and at night
• Any injury
• Weight loss, fever, night sweats
• Any past cancer; breast lumps
• Contact with tuberculosis
• Numbness or weakness in the legs; bladder or bowel changes
• Steroids, thinning of the bones, menopause
• Other bone pain

Red flags

• Pain in the middle of the back, at night or getting steadily worse
• Weight loss or fever
• Past cancer
• Numbness, weakness, bladder or bowel changes
• Steroid use

What to examine

• The spine: tenderness, shape
• A full neurological examination of the legs, and a sensory level
• Breasts, lymph nodes, abdomen
• Temperature

First investigations

• Full blood count, ESR and CRP
• Calcium, alkaline phosphatase, kidney function
• Protein electrophoresis
• MRI of the whole spine
• Chest X-ray
• Further tests as the findings direct: tuberculosis tests, breast imaging, biopsy

Differential diagnosis of back pain that wakes her at night

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Being reassured by the normal tests from months ago.
• Skipping the neurological examination.
• Not examining the breasts.