Back pain differential diagnosis: Difference between revisions

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Angiography
Angiography
* Allows 3D construction of aorta
* Allows 3D construction of aorta
Echocardiography
Echocardiography (Transesophageal)
* Demonstrates fluid shift and need for cardiology intervention  
* Demonstrates fluid shift and need for cardiology intervention  
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Ultrasonography
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* Visualization of aneurysm, size and/or rupture and hematoma
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Chest radiography
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* Visualizes calcifications in aneurysm but not specific
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CT
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* Demonstrates aortic size, extent, and involvement of organ arteries
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MRI
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* Has advantage of less radiation and no use for dye, whilst demonstrating same findings as ultrasound and CT
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Angiography
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* Allows 3D construction of aorta
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Echocardiography (Transesophageal)
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* Demonstrates fluid shift and need for cardiology intervention
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Revision as of 17:49, 28 March 2018

Back pain Microchapters

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Back Pain

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


An expert algorithm to assist in the diagnosis of back pain can be found here

Overview

There are several life-threatening causes of back pain which need to be evaluated for first, which include; spinal cord or cauda equina compression, aortic dissection, aortic aneurysm, vertebral osteomyelitis, epidural abscess, and metastatic cancer. The other possible causes of back pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.

Differential Diagnosis

Life Threatening Causes

Life threatening diseases to exclude immediately include:[1][2][3][4][2][3][5][6][7][8][9][10][11][12][13][14][15][16][17]

Common Causes

Differential Diagnosis of Back Pain

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
Vascular Aortic dissection[18][19][20][20][21][22] 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
Aortic aneurysm

rupture[23][24][25] - 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 findings on labs
 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
Chronic stable angina[26][27] 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
Pulmonary embolism[28][29] Acute Minutes Sharp All over chest and back +/- - - +/- +/- +/- - - - +/- +/- - - Lab findings are not specfic and are done to rule out other diseases such as:
    • Antithrombin III deficiency
    • Protein C or 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

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
Retroperitoneal hematoma Acute or subacute Minutes to hours
Waterhouse-Friderichsen syndrome Acute Minutes to hours
Neurological Arachnoiditis Acute Hours
Cauda equina syndrome Acute Hours
Epidural abscess Acute Variable
Radiculopathy Acute Variable
Sciatica Acute Minutes to hours
Spinal cord compression

- Thoracic spine

- Lumbar spine

Acute Minutes to hours
Bone Ankylosing spondylitis Subacute or chronic Years
Bertolotti's syndrome (Lumbosacral transitional vertebrae) Chronic Years
Chronic recurrent focal osteomyelitis Chronic Years
Cervical fracture Acute Minutes to hours
Degenerative disc disease Subacute or chronic Years
Disc herniation Acute Minutes to hours
Discitis Chronic Years
Hyperkyphosis Chronic Years
Osteoarthritis Chronic Years
Sacroiliac joint dysfunction Chronic Years
Sacroilitis Acute or chronic Variable
Scheuermann (juvenile) kyphosis Chronic Years
Scoliosis Chronic Years
Spinal stenosis Chronic
Spondylosis Chronic
Vertebral compression fracture Acute
Vertebral osteomyelitis Chronic
Non-spinal infections Appendicitis Acute
Endocarditis Acute or subacute
Cholelithiasis Acute or subacute Minutes or hours
Cystitis Acute
Myalgia Chronic
Nephrolithiasis Acute
Pancreatitis Acute or chronic Variable
Pyelonephritis Acute or chronic
Pelvic inflammatory disease Acute or chronic
Pneumonia Acute or chronic Variable
Pyomyositis Acute or chronic
Rheumatoid arthritis Chronic Years
Tumors Ewing's sarcoma Chronic
Langerhans cell histiocytosis (eosinophilic granulomas) Chronic
Leukemia Acute or chronic
Lymphoma Chronic
Neurofibroma Chronic
Osteoblastoma Chronic
Osteoid osteoma Chronic
Osteosarcoma Chronic
Prostate cancer Chronic
Muscle-related Abnormal posturing Chronic
Muscle spasm Acute
Pyriformis syndrome Chronic
Miscellaneous Chronic fatigue syndrome Chronic
Depression Chronic
Herpes zoster Acute or chronic Variable
Pregnancy Chronic
Premenstrual syndrome Acute
Sickle cell anemia Acute or chronic
Syringomyelia Chronic
Trauma Acute or chronic
Ureteropelvic junction obstruction Acute

References

  1. ↑ Chou R, Qaseem A, Owens DK, Shekelle P (February 2011). "Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians". Ann. Intern. Med. 154 (3): 181–9. doi:10.7326/0003-4819-154-3-201102010-00008. PMID 21282698.
  2. ↑ 2.0 2.1 Schiff D, O'Neill BP, Suman VJ (August 1997). "Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach". Neurology. 49 (2): 452–6. PMID 9270576.
  3. ↑ 3.0 3.1 Deyo RA, Diehl AK (1988). "Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies". J Gen Intern Med. 3 (3): 230–8. PMID 2967893.
  4. ↑ Sun JC, Xu T, Chen KF, Qian W, Liu K, Shi JG, Yuan W, Jia LS (April 2014). "Assessment of cauda equina syndrome progression pattern to improve diagnosis". Spine. 39 (7): 596–602. doi:10.1097/BRS.0000000000000079. PMID 24150427.
  5. ↑ Jarvik JG, Deyo RA (October 2002). "Diagnostic evaluation of low back pain with emphasis on imaging". Ann. Intern. Med. 137 (7): 586–97. PMID 12353946.
  6. ↑ Underwood MR, Dawes P (November 1995). "Inflammatory back pain in primary care". Br. J. Rheumatol. 34 (11): 1074–7. PMID 8542211.
  7. ↑ "Acute low back problems in adults: assessment and treatment. Agency for Health Care Policy and Research". Clin Pract Guidel Quick Ref Guide Clin (14): iii–iv, 1–25. December 1994. PMID 7987418.
  8. ↑ Ropper AH, Zafonte RD (March 2015). "Sciatica". N. Engl. J. Med. 372 (13): 1240–8. doi:10.1056/NEJMra1410151. PMID 25806916.
  9. ↑ Delitto A, Piva SR, Moore CG, Fritz JM, Wisniewski SR, Josbeno DA, Fye M, Welch WC (April 2015). "Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial". Ann. Intern. Med. 162 (7): 465–73. doi:10.7326/M14-1420. PMID 25844995.
  10. ↑ Papadopoulos EC, Khan SN (January 2004). "Piriformis syndrome and low back pain: a new classification and review of the literature". Orthop. Clin. North Am. 35 (1): 65–71. doi:10.1016/S0030-5898(03)00105-6. PMID 15062719.
  11. ↑ Hopayian K, Song F, Riera R, Sambandan S (December 2010). "The clinical features of the piriformis syndrome: a systematic review". Eur Spine J. 19 (12): 2095–109. doi:10.1007/s00586-010-1504-9. PMC 2997212. PMID 20596735.
  12. ↑ Potter NA, Rothstein JM (November 1985). "Intertester reliability for selected clinical tests of the sacroiliac joint". Phys Ther. 65 (11): 1671–5. PMID 2932746.
  13. ↑ Russel AS, Maksymowych W, LeClercq S (December 1981). "Clinical examination of the sacroiliac joints: a prospective study". Arthritis Rheum. 24 (12): 1575–7. PMID 7326071.
  14. ↑ Levangie PK (November 1999). "Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain". Phys Ther. 79 (11): 1043–57. PMID 10534797.
  15. ↑ Riddle DL, Freburger JK (August 2002). "Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study". Phys Ther. 82 (8): 772–81. PMID 12147007.
  16. ↑ Irwin RW, Watson T, Minick RP, Ambrosius WT (January 2007). "Age, body mass index, and gender differences in sacroiliac joint pathology". Am J Phys Med Rehabil. 86 (1): 37–44. PMID 17304687.
  17. ↑ Jancuska JM, Spivak JM, Bendo JA (2015). "A Review of Symptomatic Lumbosacral Transitional Vertebrae: Bertolotti's Syndrome". Int J Spine Surg. 9: 42. doi:10.14444/2042. PMC 4603258. PMID 26484005.
  18. ↑ Suzuki T, Distante A, Eagle K (November 2010). "Biomarker-assisted diagnosis of acute aortic dissection: how far we have come and what to expect". Curr. Opin. Cardiol. 25 (6): 541–5. doi:10.1097/HCO.0b013e32833e6e13. PMID 20717014.
  19. ↑ Wang Y, Tan X, Gao H, Yuan H, Hu R, Jia L, Zhu J, Sun L, Zhang H, Huang L, Zhao D, Gao P, Du J (January 2018). "Magnitude of Soluble ST2 as a Novel Biomarker for Acute Aortic Dissection". Circulation. 137 (3): 259–269. doi:10.1161/CIRCULATIONAHA.117.030469. PMID 29146682.
  20. ↑ 20.0 20.1 Akutsu K, Yamanaka H, Katayama M, Yamamoto T, Takayama M, Osaka M, Sato N, Shimizu W (November 2016). "Usefulness of Measuring the Serum Elastin Fragment Level in the Diagnosis of an Acute Aortic Dissection". Am. J. Cardiol. 118 (9): 1405–1409. doi:10.1016/j.amjcard.2016.07.052. PMID 27666178.
  21. ↑ Suzuki T, Katoh H, Tsuchio Y, Hasegawa A, Kurabayashi M, Ohira A, Hiramori K, Sakomura Y, Kasanuki H, Hori S, Aikawa N, Abe S, Tei C, Nakagawa Y, Nobuyoshi M, Misu K, Sumiyoshi T, Nagai R (October 2000). "Diagnostic implications of elevated levels of smooth-muscle myosin heavy-chain protein in acute aortic dissection. The smooth muscle myosin heavy chain study". Ann. Intern. Med. 133 (7): 537–41. PMID 11015167.
  22. ↑ Marshall LM, Carlson EJ, O'Malley J, Snyder CK, Charbonneau NL, Hayflick SJ, Coselli JS, Lemaire SA, Sakai LY (October 2013). "Thoracic aortic aneurysm frequency and dissection are associated with fibrillin-1 fragment concentrations in circulation". Circ. Res. 113 (10): 1159–68. doi:10.1161/CIRCRESAHA.113.301498. PMID 24036495.
  23. ↑ Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ (October 2009). "The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines". J. Vasc. Surg. 50 (4 Suppl): S2–49. doi:10.1016/j.jvs.2009.07.002. PMID 19786250.
  24. ↑ Sullivan CA, Rohrer MJ, Cutler BS (June 1990). "Clinical management of the symptomatic but unruptured abdominal aortic aneurysm". J. Vasc. Surg. 11 (6): 799–803. PMID 2359191.
  25. ↑ Lesperance K, Andersen C, Singh N, Starnes B, Martin MJ (June 2008). "Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: disparities in outcomes from a nationwide perspective". J. Vasc. Surg. 47 (6): 1165–70, discussion 1170–1. doi:10.1016/j.jvs.2008.01.055. PMID 18394857.
  26. ↑ Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A (January 2007). "Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study". J Am Dent Assoc. 138 (1): 74–9. PMID 17197405.
  27. ↑ Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L (January 1985). "Acute chest pain in the emergency room. Identification and examination of low-risk patients". Arch. Intern. Med. 145 (1): 65–9. PMID 3970650.
  28. ↑ Lassila R, Jula A, Pitkäniemi J, Haukka J (November 2014). "The association of statin use with reduced incidence of venous thromboembolism: a population-based cohort study". BMJ Open. 4 (11): e005862. doi:10.1136/bmjopen-2014-005862. PMC 4225235. PMID 25377011.
  29. ↑ Horlander KT, Mannino DM, Leeper KV (July 2003). "Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data". Arch. Intern. Med. 163 (14): 1711–7. doi:10.1001/archinte.163.14.1711. PMID 12885687.


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