Back pain and stiffness

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
Neurological	Arachnoiditis	Acute	Hours	Dull aching pain	Head, neck and back	+/-	+	+/-	+/-	+/-	+/-	+/-	+/-	+/-	-	-	+/-	+/-	CSF Elevated protein with normal or low glucose Culture and sensitivity May be due to TB or Meningitis Nucleic acid tests Helpful in tuberculous meningitis	Radiography Thickened nerve roots CT Narrowing of subarachnoid space Irregular collections of contrast material Thickened nerve roots MRI Study of choice shows indistinct cord outline	Usually caused by meningitis or TB
	Radiculopathy	Acute	Variable	Severe, shooting pain	Anterior thigh and knee	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	Typically no specific lab findings	Radiography To rule out serious underlying etiology CT Demonstrates disc herniation MRI Demonstrates disc herniation and nerve root impingement Myelography Used preoperatively to visualize spinal anatomy accurately Discography To localize a symptomatic disc Disc herniation is the most common cause of nerve impingement
	Sciatica	Acute	Minutes to hours	Severe, shooting pain	Posterior thigh, buttocks and knee	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	To exclude other pathologies CBC with differential ESR Alkaline and acid phosphatase level Serum calcium level Serum protein electrophoresis	Radiography With technetium-99m labeled phosphorus to indicate bone mineralization status CT Demonstrates disc herniation MRI Demonstrates disc herniation and nerve root impingement Myelography Used preoperatively to visualize spinal anatomy accurately Discography To localize a symptomatic disc	May have a psychological component
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
Bone	Ankylosing spondylitis	Subacute or chronic	Years	Dull aching pain	Local	+	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings	MRI Demonstrates both inflammatory and structural lesions CT Useful in identifying structural lesions Radiography Useful in identifying structural lesions Doppler ultrasound To detect active esthesitis	Extra-articular manifestations are common and include Uveitis CVD Respiratory disease Renal disease Neurologic disease GI disease Metabolic bone disease Often affecting a young male
	Chronic recurrent focal osteomyelitis	Chronic	Years	Dull aching pain	Local	+/-	+	+	-	-	-	+/-	-	-	-	-	-	-	CBC Leukocytosis and left shift ESR Elevated CRP Elevated Procalcitonin Elevated Culture and sensitivity To identify causative agent	Radiography Demonstrates endosteal or medullary lesion Sequestration and cavity formation MRI Bone marrow abnormalities and lytic changes CT Articular and periarticular involvement Ultrasound Soft tissue abnormalities Nuclear imaging Loss of bone density	Acute presentation is often seen in children and is associated with gait abnormalities
	Degenerative disc disease	Subacute or chronic	Years	Dull aching	Local	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	+/-	Serology HLA-B27 may be positive or negative IgA may be elevated ANA may be positive Rheumatoid factor may be positive CBC May indicate anemia ESR May be elevated CRP May be elevated Uric acid May be elevated	MRI Demonstrates delineation and position of vertebrae CT Demonstrates delineation and position of vertebrae May also visualize nerve root compression and nerve swelling Diskography Controversial, demonstrates disc herniation	Transforaminal selective nerve root blocks are used diagnostically and therapeutically in cases presenting with radicular pain
	Hyperkyphosis	Chronic	Years	Dull aching	Local	+/-	-	-	-	-	-	-	+/-	+/-	-	-	-	-	Typically no specific lab findings, however; CBC may be done to rule out other serious pathologies.	Radiography Wedge-shaped vertebrae Narrow intervertebral disk spaces with calcifications Prominent irregularities of vertebrae Arcuate kyphosis	Often begins as loss of height with normal aging
	Osteoarthritis	Chronic	Years	Dull aching	Local	+	-	-	-	-	-	-	-	-	-	-	-	-	ESR Elevated CRP Elevated Synovial fluid analysis WBCs < 2000/mm3 Polys < 25% Culture negative Crystal negative Elevated IL-2, IL-5, MCP-1	Radiography Asymmetric joint space narrowing Subchondral sclerosis Subchondral cysts MRI Joint space narrowing Degeneration	Gradual onset Polyarthritis Hips, knees, distal and proximal interphalyngeal joints and spine involvement Bouchard's and Heberden's nodes
	Sacroiliac joint dysfunction	Chronic	Years	Dull aching	Hips and legs	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	CBC May show leukocytosis ESR May be elevated CRP May be elevated Serology ANA Rheumatoid factor HLA-B27 Metabolic panel May indicate hypothyroidism or cortisol abnormalities	Imaging is controversial, however, CT may demonstrate; Reactive spurs Sclerosis Subluxation MRI Used primarily to exclude disc herniation Nuclear imaging Used to rule out stress fractures and metastatic bone disease	Rehabilitation is often sought
	Sacroilitis	Acute or chronic	Variable	Dull aching or throbbing	Hips and legs	+/-	+	+/-	-	-	-	+/-	+/-	+/-	-	-	+/-	-	CBC May demonstrate leukocytosis ESR May be elevated CRP May be elevated Procalcitonin May be elevated Culture and sensitivity To identify causative agent	MRI Narrowing of joint space and low signalling indicates edema CT Detects lesions earlier than radiography, demonstrates hypodensity of joint space and destruction of articular surface Radiography Joint space narrowing with destruction of joint space Nuclear imaging Focal uptake of gallium-67 and technetium-99m in area of destruction	Most likely due to hematogenous spread of organism
	Scheuermann (juvenile) kyphosis	Chronic	Years	Dull aching	Shoulders and arms	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings	Radiography Wedge-shaped vertebra Arcuate kyphosis Narrow intervertebral discs with calcifications Prominent irregularities of the vertebrae Vertebral plates are underdeveloped and demonstrate multiple herniations of the nucleus pulposus (Schmorl nodes)	Schmorl nodes are also seen in Wilson's disease and are not specific
	Scoliosis	Chronic	Years	Dull aching	Shoulders, arms, hips and legs	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	Typically no specific lab findings	Radiography Bending of the thoracic curve is noted MRI Used to assess additional complaints such as headaches, not routine for adolescents	Most commonly is idiopathic
	Spinal stenosis	Chronic	Years	Dull aching	Hips and legs	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	+/-	Typically no specific lab findings	MRI Demonstrates narrowing of central canal, lateral recess, and neuronal foramina CT Demonstrates narrowing of central canal, lateral recess, and neuronal foramina	Premature imaging is strongly not recommended and may harm patient Normal aging process
	Spondylosis	Chronic	Years	Dull aching	Shoulders, arms, hips and legs	+/-	-	-	+/-	-	-	-	+/-	+/-	-	-	+/-	+/-	Typically no specific lab findings	Radiography Demonstrates osteophytes and disc-space narrowing MRI Demonstrates the location of destruction and surrounding soft tissue CT myelography Demonstrates osteophytes and calcified opacities	Progresses with aging
	Vertebral compression fracture	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	-	-	+/-	+/-	+/-	-	+/-	+/-	-	-	+/-	-	CBC Decreased hematocrit and anemia PSA To rule out prostate cancer Urine analysis To detect Bence - Jones protein Serum protein electrophoresis M spike is seen with multiple myeloma ESR May be elevated	Radiography Decreased vertebral body height CT Detects more subtle fractures and calcifications MRI Useful in those with motor weakness and sensory deficits May demonstrate hemorrhage, tumor, or infection DRA scanning Detects low bone density PET scanning To distinguish benign from malignant causes of compression	Presents as a midline back pain
	Vertebral osteomyelitis	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	+	+/-	-	+/-	-	-	+/-	+/-	-	-	+/-	-	CBC Leukocytosis and left shift ESR Elevated CRP Elevated Procalcitonin Elevated Culture and sensitivity To identify causative agent	Radiography Demonstrates endosteal or medullary lesion Sequestration and cavity formation MRI Bone marrow abnormalities and lytic changes CT Articular and periarticular involvement Ultrasound Soft tissue abnormalities Nuclear imaging Loss of bone density	Often caused by hematogenous spread of organism
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	Myalgia	Chronic	Years	Dull aching	Variable	+/-	+/-	+/-	+/-	-	-	-	-	-	-	-	-	-	*Typically no specific lab findings A full workup should be done to exclude other etiologies, such as; Rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies May indicate cause is rheumatoid arthritis CRP and ESR May be elevated CBC May indicate anemia Bone profile May be caused by a vitamin D or calcium deficiency	Typically no routine imaging done	May be associated with Hepatitis C and Lyme disease
	Rheumatoid arthritis	Chronic	Years	Severe, aching	Variable	+	-	-	-	-	-	+/-	-	-	-	-	-	-	ESR and CRP Elevated CBC May indicate anemia Rheumatoid factor May be positive ANA May be positive Anti−cyclic citrullinated peptide (anti-CCP) and anti−mutated citrullinated vimentin (anti-MCV) Are specific to rheumatoid arthritis	Radiography Osteopenia is noted Metacarpal bone erosion Narrow joint space without osteophytes MRI Pannus formation may be noted Ultrasound Effusion of joint may be seen	Symmetric polyarthritis Morning stiffness with improvement throughout the day Deformities of the hand are common
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
Tumors	Ewing's sarcoma	Chronic	Months to years	Dull aching	Variable	+/-	+/-	+/-	-	-	-	+	-	-	-	-	-	-	Tests are used to rule out other pathologies; CBC May indicate anemia Blood cultures May be positive for various organisms ESR and CRP May be elevated LDH May be elevated Cytogenetic studies May be positive for t(11;22) translocation Immunohistochemical markers May be positive for MIC2 antigen (CD99)	Radiography Periosteal reaction "onion skin" Cortical thinning Mottling MRI Skip lesions Edema Metastasis PET - FDG To identify metastatic disease
	Multiple myeloma	Chronic	Years	Dull aching	Hips, groin and legs	+/-	+/-	+/-	-	-	-	+/-	-	-	-	-	+/-	-	Serum protein electrophoresis May demonstrate a M peak Serum free light chain assay and 24 - hour urine collection May detect Bence-Jones proteins CRP May be elevated Serum beta2-microglobulin May be elevated Albumin May demonstrate elevated albumin in urine LDH May be elevated Peripheral blood smear May demonstrate rouleaux formation > 50% Leukopenia Thrombocytopenia	Radiography, MRI and PET Osteolytic lesions may be demonstrated	Biopsy will demonstrate elevated plasma cells in the bone marrow
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
Muscle-related	Abnormal posturing	Chronic	Years	Dull aching	Shoulders, arms, hips, legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings	Typically no routine imaging done, diagnosed clinically	Back brace maybe used with gentle exercise
	Pyriformis syndrome	Chronic	Years	Aching	Hips and legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings	MRI and ultrasound May be utilized in non-resolution of muscle spasm to visualize the soft tissue	Rest, bandaging and topical analgesics are often used to treat
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
Miscellaneous	Chronic fatigue syndrome	Chronic	Years	Dull aching	Variable	+/-	-	-	+/-	+/-	-	-	-	-	-	-	-	-	Typically no specific lab findings, however, serology may be somewhat specific and demonstrate; Elevated IgM and/or IgG in coxsackie virus B titer Elevated IgM and/or IgG human herpes virus 6 titer Elevated IgM/IgG in C pneumoniae titer Decrease in natural killer cell percentage or activity Labs used to exclude other pathologies include; CBC May demonstrate leukopenia or leukocytosis LFT May demonstrate elevated serum transaminases, alkaline phosphatase, or lactic dehydrogenase TFT To rule out hypo/hyperthyroidism ESR Usually low Serum electrolytes Hypokalemia or hypocalcemia may be noted ANA May indicate an autoimmune disease Cortisol May indicate pathology of the adrenal gland Serum protein electrophoresis To rule out myeloma or lymphoma	CT and MRI Used to exclude other pathologies PET May demonstrate hypoperfusion of the frontoparietal and/or temporal region of the brain	Usually diagnosed by exclusion
	Depression	Chronic	Months to years	Severe to mild aching	Variable	+/-	-	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	Typically no specific lab findings Lab testing is used to diagnose organic causes and include; CBC TFT Vitamin B-12 detection Rapid plasma reagin HIV testing Electrolytes, especially calcium, phosphate, and magnesium levels BUN and creatinine LFTs Blood alcohol level Blood and urine toxicology screen ABG Dexamethasone suppression test Cosyntropin stimulation test	CT and MRI To rule out organic brain syndrome or hypopituitarism PET Allows for study of ligand-receptor binding SPECT May demonstrate regional blood flow deficits in the left anterofrontal and temporal regions	Must assess suicidal ideation
	Pregnancy	Chronic	Pregnancy term	Dull aching	Groin, hips, legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Beta - human chorionic gonadotropin If detected usually confirms pregnancy	Typically no routine imaging is done to prevent radiation exposure, unless complication occurs an MRI may be carried out
	Sickle cell anemia	Acute or chronic	Variable	Severe, sharp	Variable	+/-	+	+/-	-	-	-	-	-	-	-	-	-	-	CBC Hemoglobin level is between 5-9 g/dl Hematocrit is decreased to 17-29% Leukocytosis with predominance of neutrophils Thrombocytopenia ESR Decreased Reticulocyte count Elevated Peripheral blood smear May demonstrate target cells, elongated cells, and sickle erythrocytes Howell - Jolly bodies in an asplenic patient Hemoglobin solubility Distinguishes between sickle cell disease and sickle cell trait Hemoglobin F Percentage of Hemoglobin F is elevated LFT, renal function test and pulmonary function test To assess organ distress or failure ABG To detect oxygen saturation Urine analysis May determine an urinary tract infection with hematuria and isosthenuria Sickling test As screening for sickle hemoglobinopathies Secretory phospholipase A2 May be increased in acute chest syndrome, a complication of sickle cell disease	Radiography Osteonecrosis Dactylitis indicated by medullary expansion, cortical thinning, trabecular resorption, and bone lucency Osteomyelitis may be present and demonstrate sequestra, cortical destruction, periosteal growth and sinus formation MRI and CT In addition to findings in radiography, may detect bone marrow hyperplasia May also be useful in ruling out renal medullary carcinoma in those presenting with hematuria Nuclear imaging Used to detect early osteonecrosis through Technetium-99m bone scanning Used to detect early osteomyelitis through detection of elevation ofwhite blood cells in Indium-11 white blood cell scanning Transcranial doppler ultrasonography Abnormally high blood flow is detected in those at increased risk of stroke Abdominal ultrasound Used to exclude other pathologies such as, cholecystitis, cholelithiasis, ectopic pregnancy, nephrolithiasis, and papillary necrosis May also be used to asses the size of the liver and spleen Echocardiography Used to diagnose pulmonary hypertension based on tricuspid regurgitant jet velocity Also used to assess abnormalities of systolic and diastolic function	Sickle cell trait confers some protection against malaria
	Syringomyelia	Chronic	Years	Dull aching	Variable	+/-	+/-	-	+/-	+/-	-	-	-	-	-	-	-	-	*Typically no specific lab findings	MRI Of choice and demonstrates a syrinx (spinal cord cyst) May also be useful in assessment of CSF flow dynamics Radiography and CT May also visualize a syrinx Gadolinium scan Useful in assessment of post-operative patients and can distinguish between a tumor, scar, and disk material Myelography Used when MRI is unfruitful, and may detect widening of spinal cord and complete subarachnoid block
	Trauma	Acute or chronic	Variable	Severe, sharp to dull aching	Variable	+/-	-	-	-	+/-	+/-	-	+/-	+/-	-	-	+/-	+/-	After establishment of first aid protocol, the following lab tests may be useful; Pregnancy test In women of child-bearing age Blood typing, screening and cross matching In case of blood transfusion Prothrombin time To assess those taking warfarin Creatine kinase To determine incidence of rhadomyolysis Blood sugar To determine hypoglycemia Cardiac enzymes To determine incidence of myocardial infarction Toxicology screen and alcohol level To determine alcoholism and drug use Serum lactate Elevated serum lactate may indicate a serious injury	To assess trauma, the following imaging may be used; Portable radiography Ultrasound CT Peritoneal tap or lavage Echocardiography