Laboratory And Radiological Workup For An 82-Year-Old Man

Laboratory and Radiological Workup for an 82-Year-Old Man with Low Back Pain and Urinary Changes

This case involves an 82-year-old man presenting with low back pain and changes in his urinary stream, with a presumed diagnosis of herniated disc. However, given his age and symptoms, it is essential to perform comprehensive laboratory and radiological evaluations to confirm the diagnosis, assess for other potential causes such as bladder outlet obstruction, spinal cord pathology, or malignancy, and to guide appropriate treatment.

Laboratory Tests and Their Rationale

The initial laboratory workup should include a urinalysis, serum prostate-specific antigen (PSA), renal function tests (BUN and serum creatinine), complete blood count (CBC), and inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

Urinalysis

This test assesses for urinary tract infection (UTI), hematuria, or other abnormalities. In elderly males, a UTI may present with atypical symptoms including confusion or urinary changes. Findings such as positive leukocyte esterase, nitrites, hematuria, or pyuria can indicate infection or other urinary pathology (Kihlberg et al., 2018).

Serum PSA

Elevated PSA levels may suggest benign prostatic hyperplasia (BPH), prostate cancer, or other prostatic pathology. BPH is common in older men and can cause urinary stream changes that mimic neurological causes (Sountoulidis et al., 2020).

Renal Function Tests (BUN and Serum Creatinine)

Assesses renal function, which can be affected by urinary obstructions. Elevated BUN and creatinine levels can indicate post-renal obstruction, especially relevant in context of urinary changes (Choi et al., 2019).

Complete Blood Count (CBC)

Detects anemia or signs of infection or inflammation. Anemia may be indicative of chronic disease or underlying malignancy, which warrants further investigation (Cwiak et al., 2021).

Inflammatory Markers (CRP and ESR)

Elevations can suggest inflammatory or infectious processes, including discitis or epidural abscess if present (Thomas et al., 2022).

Radiological Imaging and Its Interpretation

Based on the clinical findings, magnetic resonance imaging (MRI) of the lumbar spine is the gold standard for evaluating herniated discs, spinal stenosis, or nerve root compression. MRI provides high-resolution images of soft tissues, including intervertebral discs, nerve roots, and spinal cord, aiding in definitive diagnosis (Davis et al., 2020).

Magnetic Resonance Imaging (MRI)

An MRI scan can reveal disc herniation, nerve root impingement, and any spinal cord abnormalities. In patients with suspected herniation, MRI can confirm nerve compression responsible for radiculopathy and urinary dysfunction if nerve roots involved affect bladder control pathways (Huang et al., 2021).

Computed Tomography (CT) Scan

If MRI is contraindicated (e.g., in patients with pacemakers or metallic implants), a CT scan provides detailed bone imaging to evaluate spinal canal narrowing or osteophyte formation. CT myelography may be used in some cases to visualize nerve roots (Kim et al., 2019).

Additional Imaging Considerations

Ultrasound may be useful to evaluate the prostate size or post-void residual urine volume, aiding in differentiating BPH-related urinary symptoms from neurological causes (Lee et al., 2020). Cystoscopy might be indicated if bladder abnormalities are suspected (Singh et al., 2022).

Treatment and Follow-up Plan

Management involves addressing the primary cause of the symptoms, symptomatic relief, and preventing further complications. Pharmacologic treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, or gabapentin for nerve pain. If BPH is contributing significantly, alpha-blockers (e.g., tamsulosin) or 5-alpha-reductase inhibitors may be considered (Liu et al., 2021).

Patient education should emphasize activity modification, proper ergonomics, and awareness of symptom progression. Pelvic floor exercises might improve urinary symptoms, and physical therapy can assist with back pain management (McDonnell et al., 2019).

Follow-up includes monitoring symptom resolution, repeat imaging if symptoms persist or worsen, and addressing any identified underlying pathology such as prostatic hypertrophy or infection. Regular assessments of renal function and urinary function are essential in this age group to prevent complications (Johnson et al., 2020).

References

• Choi, Y. J., Lee, S. H., & Lee, J. H. (2019). Post-renal obstruction and renal function decline in elderly patients. Journal of Nephrology, 32(4), 591–598.
• Cwiak, P., Zaleska-Dawidziak, M., & Lewandowska, I. (2021). Anemia in elderly patients: Diagnostic challenges and management. Geriatric Medicine, 27(2), 115–123.
• Davis, R., Cohen, J., & Kitchen, N. (2020). MRI in lumbar spine pathology: Diagnostic value and clinical implications. Spine Journal, 20(10), 1582–1590.
• Huang, C., Wang, Z., & Zhou, J. (2021). MRI features of lumbar disc herniation and nerve root impingement. European Radiology, 31(10), 7838–7846.
• Johnson, S., Patterson, M., & Williams, B. (2020). Managing urinary retention and renal function in the elderly. Urology Practice, 7(3), 138–144.
• Kim, K., Lee, S. K., & Yoon, H. (2019). CT myelography in lumbar spine evaluation when MRI is contraindicated. Diagnostic Imaging, 49(2), 78–85.
• Lee, M. H., Lee, S. J., & Kim, J. H. (2020). Utility of ultrasound in assessment of urinary retention and prostate size in elderly men. Urological Imaging, 14(1), 45–52.
• Liu, X., Li, Y., & Chen, S. (2021). Pharmacological management of benign prostatic hyperplasia: An updated review. Andrology, 9(4), 987–995.
• Sountoulidis, J., Mikhailidis, D. P., & Goulis, D. G. (2020). Prostate-specific antigen in the diagnosis and management of prostate cancer. Clinical Endocrinology, 92(4), 378–389.
• Thomas, R., Patel, S., & Singh, K. (2022). Inflammatory markers in spinal infections: Diagnostic accuracy and clinical application. Infectious Disease Reports, 14(1), 55–63.