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JAMA Surgery Clinical Challenge
December 2018

Chronic Back Pain and a Bulge

Author Affiliations
  • 1Department of Surgery, St John Macomb-Oakland Hospital, Warren, Michigan
JAMA Surg. 2018;153(12):1149-1150. doi:10.1001/jamasurg.2018.2024

A 65-year-old woman was seen at the surgical clinic with reports of chronic back pain and a bulge in her back. History revealed multilevel cervical and lumbar fusion surgical procedures using anterior, left lateral, and posterior approaches over a 10-year period. The patient subsequently noted a new, slowly enlarging bulge in her left midback that was bothersome with activities of daily living (Figure, A). She denied pain directly overlying the area and was otherwise tolerating a regular diet and having usual bowel function. Physical examination revealed a soft bulge in the lateral left midback. There were no apparent associated skin changes, and the palpable mass appeared fixed and nonreducible. The mass was most apparent with upright posture and was accentuated with a cough impulse, but it was less distinct when examined in the prone position. Computed tomography of the abdomen and pelvis was obtained (Figure, B).

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