title: A case study of back pain and renal cell carcinoma.
abstract: OBJECTIVE
  Renal cell carcinoma accounts for 3% of adult malignancy and 95% of neoplasms arising from the kidney. One third of the patients have metastatic disease at the time of presentation and are asymptomatic with the diagnosis being made incidentally from a radiologic study obtained for other reasons. Typically, skeletal metastases are purely lytic. It is common for cases of back pain to be managed in chiropractic clinics. The diagnosis of metastatic disease is to be considered as a differential, especially in an aging population.
  
  
  METHODS
  A 69-year-old man experienced back pain after a twisting movement while working. He presented for chiropractic care 2 weeks later. He had a 10-year history of low back pain and a 2-month history of weakness at the knee. Plain film radiography was assessed as negative for pathology by a medical radiologist and a chiropractic radiologist.
  
  
  RESULTS
  After 6 visits of care using atlas orthogonal adjusting, the outcome assessment revealed improvement in the pain but a regression in strength of the right quadriceps and peroneus muscles. The patient was referred for a magnetic resonance imaging study, which revealed a mass on the kidney and a large erosive bone lesion of the L4 vertebrae. The diagnosis of renal cell carcinoma was later confirmed.
  
  
  CONCLUSIONS
  Progressive muscle weakness is one of the "red flag" signs in a back pain case. Advanced imaging is necessary to detect occult diseases processes such as renal cell carcinoma. The chiropractor's role as primary care clinician includes the process of clinical reasoning and appropriate referral when the clinical picture becomes unclear and/or "red flag" signs appear.
authors.affiliation: Faculty Clinician, The Center for Health and Optimum Performance, Life University, Marietta, GA 30060.
authors.forename: Robert
authors.initials: R
authors.lastname: Rectenwald
references.citation: Clin Cancer Res. 2004 Mar 15;10(6):2015-9
references.pmid: 15041720
references.citation: J Clin Neurosci. 2004 Jun;11(5):530-2
references.pmid: 15177402
references.citation: N Engl J Med. 1996 Sep 19;335(12):865-75
references.pmid: 8778606
references.citation: CA Cancer J Clin. 2007 Mar-Apr;57(2):112-25
references.pmid: 17392388
references.citation: Eur J Surg Oncol. 2001 Jun;27(4):428-9
references.pmid: 11417991
references.citation: JAMA. 2004 Jul 7;292(1):97-100
references.pmid: 15238597
references.citation: Ann Rheum Dis. 1999 Aug;58(8):462-4
references.pmid: 10419863