Case ReportMultiple Venous Thromboses Presenting as Mechanical Low Back Pain in an 18-Year-Old Woman
Introduction
Venous thromboembolism (VTE), a blood clotting process that encompasses both deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common vascular disorder in white populations after myocardial infarction and stroke.1 An individual’s absolute lifetime risk of VTE is approximately 11%2 and its incidence rate increases exponentially with age, for both women and men.1, 3, 4 Although less frequent than DVT alone (0.93 per 1000 person-years), PE with or without DVT (0.50 per 1000 person-years)1 has a higher recurrence rate and is often fatal.3 Most cases of DVT (90%) are located in the lower limbs,5 particularly within the gastrocnemius and soleus muscles6 and become symptomatic when there is proximal vein involvement.5 Despite adequate treatment, DVT can recur, and about 10% of patients will develop severe post-thrombotic syndrome within 5 years.7 As part of the general chiropractic program, the training on VTE includes education on the usual clinical presentations, such as a “red, swollen, and hot” calf for DVTs and shortness of breath for PEs. Clinicians should be aware of the different clinical presentations of this serious pathology, as faster diagnosis and treatment may lead to a better prognosis.
The objective of this case report is to present a rare case of multiple thromboembolism events in a young woman, who first presented to a chiropractor’s clinic for acute low back pain. An overview of the risk factors, clinical presentation, diagnosis, and management will be discussed.
Section snippets
Case Report
An 18-year-old woman presented to a chiropractic clinic with left lumbosacral pain with referral into the posterior aspect of the left thigh. The pain had started suddenly, 72 hours before the consultation as the patient was pulling a cable out of the swimming pool. The pain occasionally extended below the knee with forward bending of the lumbar spine. However, the patient did not report any numbness, paresthesia, or weakness in the lower extremities. The patient characterized the nature of her
Discussion
In light of the events mentioned above, primary care physicians should recognize the importance of conducting a detailed history and physical examination when vascular peripheral involvement is suspected. The physician should screen the patient's past history for personal or family antecedents of vascular disease and known blood anomalies. Screening for potential risk factors and use of the Wells probability score (detailed in the “Diagnosis” section) should help clinicians estimate the
Limitations
Due to its nature, a case report does not allow for potential associations nor cause and effect. However, it may provide insight into clinical presentations that differ from what is usually expected. The patient experienced sudden pain following a physical effort and did get some relief from conservative chiropractic treatments. It is possible that the occurrence of the deep vein thromboses is purely coincidental and had nothing to do with the initial event and patient presentation.
Conclusion
Although VTE is a common condition in the general population, its presence in low-risk individuals can be overlooked. In the presence of subtle initial clinical signs such as those the patient in this case report presented with, clinicians should keep a high index of suspicion for a DVT. Rapid identification of such clinical signs in association with a lack of objective examination findings warrants further evaluation due to potentially negative outcomes.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
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