Back pain and pulse deficit

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Abbreviations: ABG = Arterial blood gases, ANA = Antinuclear antibodies, BUN = Blood urea nitrogen, CRP = C-reactive protein, CT = Computed tomography, DRA = Dual energy radiographic absorptiometry, DRE = Digital rectal exam, ERCP = Endoscopic retrograde cholangiopancreatography, ESR = Erythrocyte sedimentation rate, HSV = Herpes simplex virus, IVP = Intravenous pyelography, KUB = Kidney, bladder, ureter, LDH = Lactate dehydrogenase, LFT = Liver function test, MRA = Magnetic resonance angiography, MRC = Magnetic resonance cholangiopancreatography, MRI = Magnetic resonance imaging, MRU = Magnetic resonance urography, NSAIDs = Non-steroidal anti-inflammatory drugs, PCR = Polymerase chain reaction, PET - FDG = Positive emission tomography - fluorodeoxyglucose, PET = Positive emission tomography, PID = Pelvic inflammatory disease, PSA = Prostatic specific antigen, PTC = Percutaneous transhepatic cholangiography, RUQ = Right upper quadrant, SPECT = Single-photon emission computed tomography, TFT = Thyroid function test, VZV = Varicella zoster virus

Classification of pain in the back based on etiology	Diease	Clinical Manifestation																	Diagnosis		Comments
		Symptoms											Signs						Lab findings	Imaging
		Onset	Duration	Quality of pain	Radiation	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Syncopy	Weight loss	Motor weakness	Sensory deficit	Pulse Deficit	Heart Murmur	Bowel or bladder dysfunction	Horner's syndrome
Referred pain	Aortic aneurysm rupture - Abdominal aortic aneurysm - Thoracic aortic aneurysm	Acute	Minutes to hours	Sharp and knife-like, also tearing or ripping	Back and/ or flanks	-	-	-	-	-	+/-	-	-	-	+	+/-	-	-	Typically no specific lab findings, however, evidence of haemorrhage and organ injury may be seen in: Complete blood count; normochromic normocytic anemia seen in haemorrhage Elevated serum electrolytes Elevated liver function tests Elevated amylase or lipase	Ultrasonography Visualization of aneurysm, size and/or rupture and hematoma Chest radiography Visualizes calcifications in aneurysm but not specific CT Demonstrates aortic size, extent, and involvement of organ arteries MRI Has advantage of less radiation and no use for dye, whilst demonstrating same findings as ultrasound and CT Angiography Allows 3D construction of aorta Echocardiography (Transesophageal) Demonstrates fluid shift and need for cardiology intervention	Livedo reticularis may be seen and indicates thrombotic phenomenon
	Aortic dissection	Severe and sudden (acute) and rarely, chronic	Minutes to hours	Sharp and knife-like, also tearing or ripping	Back and/or flanks	-	-	-	-	-	+/-	-	-	-	+	+/-	-	-	Elevations in: D - dimer Smooth muscle myosin heavy chain Soluble ST2 Soluble elastin fragments High -sensitivity C-reactive protein Fibrinogen Fibrillin fragments	ECG: Normal Non - specific ST wave changes Hypertrophy patterns ST segment elevation indicating myocardial infarction Chest radiography: Normal Mediastinal or aortic widening	Increased risk of occurence with Marfan syndrome
	Chronic stable angina	Chronic	Variable	Discomfort in the chest	Left shoulder, arm and jaw	-	-	-	-	+/-	+/-	-	-	-	+/-	-	-	-	Detection of: Urinary proton nuclear magnetic resonance spectroscopy Toll-like receptors 2 and 4 (TLR-2 and TLR-4)  on platelets	Chest radiography Normal, may show calcification or complications such as pleural effusion Exercise stress testing Establishes diagnosis and extent of angina Stress Echo To evaluate wall motion, normal in stable angina Nuclear imaging To assess myocardial perfusion, reduced in stable angina CT To evaluate coronary artery calcium (cac) which may or may not be elevated CT Angiography To evaluate stenosis, <70% in stable angina EKG Normal in stable angina	Hallmark is relief by rest or sublingual nitroglycerin
	Endocarditis	Acute or subacute	Variable	Discomfort in the chest	Jaw and arms	-	+/-	+/-	-	+/-	+/-	-	-	-	+/-	+	-	-	CBC Anemia and leukocytosis may be noted Serology Decrease C3, C4, and CH50 may indicate subacute endocarditis Rheumatoid factor may be positive ESR May be elevated Urine analysis May demonstrate proteinuria and microscopic hematuria Blood culture To identify causative agent Streptococci and HACEK organisms are culture negative Organisms that grow on prosthetic valves tend to be coagulase-negative staphylococci	Echocardiography Vegetations and myocardial abscesses may be present Radiography Pyogenic emboli may be seen across the lung field Ultrasound Myocardial abscesses may be seen Valvular dysfunction may also be noted	IV drug users and those who suffer from rheumatic heart disease often present with infective endocarditis
	Pulmonary embolism	Acute	Minutes	Severe, sharp	Chest and back	+/-	-	-	+/-	+/-	+/-	-	-	-	+/-	+/-	-	-	Lab findings are not specfic and are done to rule out other diseases such as: Antithrombin III deficiency Protein Cor protein S deficiency Lupus Homocystinuria Malignancy Connective tissue disorders	D - dimer is positive and ventilation- perfusion scanning will show a a perfusion/ventilation mismatch CT Angiography and duplex angiography are able to visualize the embolism	PE may occur even in patients that are fully anticoagulated DVT is a common source
	Traumatic aortic rupture	Acute	Minutes to hours	Sharp and knife-like, also tearing or ripping	Back and/ or flanks	-	-	-	-	-	+/-	-	-	-	+/-	+/-	-	-	Typically no specific lab findings, however, evidence of hemorrhage and organ injury may be seen in: Complete blood count; normochromic normocytic anemia seen in hemorrhage Elevated serum electrolytes Elevated liver function tests Elevated amylase or lipase	Ultrasonography Visualization of rupture, size and hematoma CT Demonstrates intimal flap, hematoma, filling defect, aortic contour abnormality, pseudoaneurysm, vessel wall disruption, and extravasation of intravenous contrast MRI Has advantage of less radiation and no use for dye, whilst demonstrating same findings as ultrasound and CT Angiography Allows 3D construction of aorta Echocardiography (Transesophageal) Demonstrates fluid shift and need for cardiology intervention	Mostly caused by automobile accidents