Differential Diagnosis
The patient presents with a 2-month history of increasingly severe low back pain, weakness in her right leg, and difficulty walking. The presence of multiple lytic lesions on the lumbar spine x-ray is a crucial finding. Here is the differential diagnosis, categorized for clarity:
Single most likely diagnosis
- E) Vertebral body metastasis: This is the most likely diagnosis given the patient's history of smoking, which increases the risk of various cancers, and the presence of multiple lytic lesions on the lumbar spine x-ray. The gradual onset of back pain and the development of neurological symptoms such as leg weakness are consistent with metastatic disease affecting the spine.
Other Likely diagnoses
- A) Cauda equina syndrome: Although less likely than vertebral body metastasis, cauda equina syndrome could explain the patient's symptoms, especially if there is compression of the nerve roots in the lumbar spine. However, the absence of incontinence and the specific pattern of neurological deficits make this less likely.
- C) Epidural abscess: This is an infectious process that could cause back pain and neurological symptoms. However, it would typically present with fever, elevated white blood cell count, and more acute onset, which are not mentioned in the scenario.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- C) Epidural abscess: Despite being less likely, an epidural abscess is a medical emergency that requires prompt diagnosis and treatment to prevent serious neurological damage or sepsis.
- D) Spinal cord infarction: Although rare, spinal cord infarction can present with acute back pain and neurological deficits. It is crucial to consider this diagnosis due to its potential for severe and irreversible neurological damage.
Rare diagnoses
- B) Conus medullaris syndrome: This is a rare condition involving injury to the conus medullaris, the lowermost part of the spinal cord. It could present with a mix of upper and lower motor neuron signs, but it is less likely given the patient's presentation and the findings on the x-ray.
- Other rare diagnoses might include spinal hematomas or certain inflammatory conditions affecting the spine, but these are not strongly suggested by the information provided.