Back pain differential diagnosis: Difference between revisions

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Revision as of 20:00, 1 April 2018

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

The following table outlines the major differential diagnoses of back pain.

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 simplez virus, IVP = Intravenous pyelography, KUB = Kidney, bladder, ureter, LDH = Lactate dehydrogenase, LFT = Liver function test, MRC = Magnetic resonance cholangiopancreatography, MRI = Magnetic resonance imaging, 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	Lab findings	Imaging
Vascular	Retroperitoneal hematoma^[18]^[19]^[20]	Acute or subacute	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	CT with IV contrast May show venous delay and indicate renal trauma Cystography Should be considered in evaluation of hematuria and pelvic injury	Mostly caused by automobile accidents
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	Lab findings	Imaging
Neurological	Arachnoiditis^[21]	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
	Cauda equina syndrome^[22]^[23]	Acute	Hours	Severe, sharp local pain	Rarely to sacroiliac joint	-	-	-	-	-	-	-	+	+/-	-	-	+/-	-	CBC To rule out anemia Electrolytes, blood urea nitrogen, and creatinine To rule out renal failure and retroperitoneal hematoma Erythrocyte sedimentation rate To rule out inflammatory origin Syphilis serology To rule out meningovascular syphilis	Radiography May show vertebral erosions MRI Of choice and may show nerve root abnormalities Duplex For vascular abnormalities Lumbar puncture For inflammation	Electrical studies: EMG Done to rule out acute denervation SSEPs Done to rule out multiple sclerosis
	Epidural abscess^[24]^[25]	Acute	Variable	Dull, throbbing pain	Locally	-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	-	-	+/-	+/-	CBC May show leukocytosis, left shift, thrombocytopenia, and anemia ESR Elevated Culture and sensitivity To identify causative organism Immunohistochemical staining Includes gram stain, special stains for fungi and mycobacteria, also consider brucella	MRI Of choice and demonstrates fluid collection CT Demonstrates fluid collection Radiography Demonstrates osteomyelitis or vertebral collapse	LP carries risk of spread of infection
	Radiculopathy^[26]^[27]	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^[28]^[29]^[29]	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
	Spinal cord compression^[22]^[23] - Thoracic spine - Lumbar spine	Acute	Minutes to hours	Severe and localized	Locally, may radiate below lesion	-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	Neoplasm must be suspected and is ruled out by CBC - May demonstrate a pancytopenia Prothrombin time and activated partial thromboplastin time - May be prolonged Metabolic profile, including calcium level and liver function - May indicate metastasis	MRI May demonstrate tumors and collapse of intervertebral spaces May distinguish between bone lesions and malignancy Radiography May demonstrates bony destruction or calcification Nuclear imaging To identify neoplasms	Aggressive radiotherapy is often needed
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	Lab findings	Imaging
Bone	Ankylosing spondylitis^[30]^[31]	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 Respiratorydisease Renal disease Neurologic disease GI disease Metabolic bone disease Often affecting a young male
	Bertolotti's syndrome^[22] (Lumbosacral transitional vertebrae)	Chronic	Years	Dull aching pain	Local	-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings	MRI Of choice and demonstrates transitional vertebra CT Demonstrates vertebral transition Radiography Demonstrates vertebral transition	Congenital anomaly and may be asymptomatic
	Chronic recurrent focal osteomyelitis^[32]^[33]^[34]	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
	Cervical fracture^[35]^[36]	Acute	Minutes to hours	Severe, sharp	Shoulder and arm	-	-	-	+/-	-	-	-	+/-	+/-	-	-	-	+/-	Typically no specific lab findings	Radiography May demonstrate fracture of the vertebrae and/or preexisting pathology that may have lead to fracture CT May show pathology that was not noted on radiography MRI May show pathology that was not noted on radiography	If suspected should be stablized immediately
	Degenerative disc disease^[37]^[38]	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
	Disc herniation^[39]^[40]	Acute	Minutes to hours	Sharp,shooting	Legs and hips	-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	Typically no specific lab findings	MRI Demonstrates the size and location of the herniated disc and surrounding soft tissue CT myelography Useful in lateral herniations with calcification Radiography Demonstrates osteophytes, disc-space narrowing, and kyphosis Discography Controversial, may show endplate irregularites or annular tears	Often presents with parathesias and no pain
	Discitis^[41]^[42]	Chronic	Years	Dull aching or throbbing	Local	-	+	+/-	-	+/-	-	+/-	+/-	+/-	-	-	+/-	-	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 disk space and low signalling indicates edema CT Detects lesions earlier than radiography, demonstrates hypodensity of disk and destruction of endplates and calcification of annulus Radiography Disk space narrowing with destruction of endplates and calcification of annulus Nuclear imaging Focal uptake of gallium-67 and technetium-99m in area of destruction	Most likely due to hematogenous spread of organism
	Hyperkyphosis^[43]^[44]	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^[45]^[46]^[47]	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^[48]^[49]	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^[49]^[50]	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^[51]^[52]	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^[53]^[54]^[55]	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^[56]^[57]	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^[58]^[59]	Chronic^[60]	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^[61]^[62]^[63]	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	-	-	+/-	+/-	+/-	-	+/-	+/-	-	-	+/-	-	CBC Decreased hematocrit and anemia PSA To rule out prostatic 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^[64]^[65]^[66]	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	Lab findings	Imaging
Referred pain	Aortic aneurysm rupture^[67]^[68]^[69] - 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^[70]^[71]^[72]^[72]^[73]^[74]	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
	Appendicitis^[75]^[76]^[77]	Acute	Minutes to hours	Burning	Umbilicus and lower right quadrant	-	+	+/-	-	+	-	-	-	-	-	-	-	-	CBC Demonstrates leukocytosis and neutrophilia CRP May be elevated Urine analysis May demonstrate pyuria, hematuria, and/or proteinuria Urine 5-HIAA Maybe an early marker of appendictis Sudden increase may indicate necrosis	Ultrasound Demonstrates a non-compressible tubular structure CT Demonstrates an enlarged appendix with thickened walls and can detect abnormally located appendices MRI Useful in pregnant ladies KUB Radiography May detect an appendicolith Barium enema Demonstrates absent or incomplete filling Cecal spasm may be present Radionuclide scanning Appendiceal inflammation may be present	Pain begins around the umbilicus and then shifts to RUQ
	Cholelithiasis^[78]^[79]	Acute or subacute	Minutes or hours	Sharp	Tip of right shoulder	-	+/-	+/-	-	+	-	+/-	-	-	-	-	-	-	CBC Demonstrates polymorphnuclear leukocytosis LFT Elevated alanine aminotransferase and aspartate aminotransferases Elevated conjugated bilirubin Amylase and lipase Elevated	Radiography Radio-opaque stones may be present CT May indicate presence of gallstones in the distal common bile duct MRI May indicate presence of gallstones in the distal common bile duct Ultrasound May demonstrate gallbladder wall thickening (>5 mm) and gallbladder fluid and distention Gallstones may appear as echogenic foci that cast an acoustic shadow Scintigraphy May detect cystic duct obstruction ERCP Stones are seen as a filling defect and can be removed simultaneously PTC Similar to ERCP Used when ERCP is not feasible	May be completely asymptomatic
	Chronic stable angina^[80]^[81]	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
	Cystitis^[82]^[83]^[84]	Acute	Hours	Burning	Suprapubic	-	+/-	+/-	-	-	-	-	-	-	-	-	-	-	Urine analysis May demonstrate pyuria, hematuria, white blood cell casts and proteinuria Urine culture Detection of > 1000 colony-forming units/ml CBC May demonstrate leukocytosis and/or anemia	Typically no routine imaging done	Cystitis may be infectious, hemorrhagic, radiational, or sterile
	Endocarditis^[85]^[86]^[87]	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
	Myalgia^[88]^[89]^[90]	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 deficiencyDipstick urinalysis	Typically no routine imaging done	May be associated with Hepatitis C and Lyme disease
	Nephrolithiasis^[91]^[92]^[93]	Acute	Hours	Severe, sharp	Abdomen, hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-	CBC Mild leukocytosis may indicate infection Electrolytes Hypokalemia may indicate acute tubular necrosis Hypercalcemia or hypercalciuria may be detected Creatinine To identify potential renal injury with contrast Uric acid Uric acid stones sometimes occur with gout ABG May indicate acute tubular necrosis with hypokalemia and decreased bicarbonate	CT Visualizes calcium stones and other possible pathologies, such as hydronephrosis IVP Visualizes stones and entire urinary system KUB radiography Radio-opaque stones may be present Ultrasound For visualization of stones Plain renal tomography Can distinguish between intrarenal and extrarenal calcifications Retrograde pyelography Particularly useful for ureteral calculi visualization Nuclear renal imaging May determine a decreased renal function	Hypercalcemia may indicate primary or secondary hyperparathyroidism
	Pancreatitis^[94]^[95]^[96]	Acute or chronic	Variable	Severe, sharp or dull aching	Abdomen	-	+/-	+/-	-	+	+/-	+/-	-	-	-	-	-	-	Amylase and lipase Elevated LFT Elevated alkaline phosphatase, total bilirubin, aspartate aminotransferase, and alanine aminotransferase CBC May demonstrate leukocytosis Serum electrolytes May indicate hypo or hypercalcemia BUN and creatinine May be elevated Triglycerides Usually elevated, however, falsely lowered during acute attack	KUB radiography May demonstrate free air within abdomen, indicating a perforated viscus Ultrasound Used to visualize the pancreas and biliary tree May detect microlithiasis and periampullary lesions CT Pancreas may appear enlarged MRC May demonstrate a blockage within the biliary ducts ERCP May remove a blockage, however, can in fact cause pancreatitis	Usually caused by binge drinking or long standing gallstones that block the ampulla of Vater Vomiting is a common manifestation
	Pelvic inflammatory disease^[97]^[98]^[99]	Acute or chronic	Variable	Dullaching or throbbing	Hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-	CBC Leukocytosis, may indicate infection with trichomoniasis Pregnancy test To rule out ectopic pregnancy STD panel To rule out gonorrhea, chlamydia, hepatitis B and C, HIV, and syphilis Urine analysis To rule out a urinary tract infection	Transvaginal ultrasound May demonstrate anechoic structures in adnexa indicating hydrosalpinx and/or pyosalpinx Laparoscopy May demonstrate adhesions (Asherman's syndrome) or gun powder lesions (Endometriosis) or an ectopic pregnancy MRI and CT May indicate hydro and/ or pyosalpinx	Inflammation may spread to perihepatic structures (Fitz-Hugh−Curtis syndrome)
	Pulmonary embolism^[100]^[101]^[102]	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 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
	Pyelonephritis^[103]	Acute or chronic	Variable	Severe, sharp or dull aching	Groin, hips and legs	-	+	+/-	-	+/-	-	-	-	-	-	-	-	-	CRP Elevated ESR Elevated Urinalysis Pyuria Bacteriuria May be nitrite positive (gram negative organisms) Culture positibe (Uncomplicated: E. coli, Proteus mirabialis, Klebsiella, S. saprophyticus- Complicated: E. coli, enterococci, S.epidermidis	Ultrasound Hydronephrosis Non-contrast CT Pelvicalceal dilation Cortical involvement MRI T1: affected region(s) appear hypointense compared with the normal kidney parenchyma T2: hyperintense compared to normal kidney parenchyma T1 C+: reduced enhancement	Renal stones Obstruction Pregnancy Prolonged urinary catheterization
	Pneumonia^[104]^[105]^[106]	Acute or chronic	Variable	Variable	Chest, back and abdomen	-	+	+	+/-	+/-	+/-	+/-	-	-	-	-	-	-	CBC Leukocytosis is often demonstrated however, white blood cell count may be normal Blood culture To identify causative organism or rule out other organisms such as MRSA	Radiography Plain x-ray shows multiple patches in the lung fields CT Used to distinguish pneumonia from non-pneumonias	Hospital-acquired pneumonia is common
	Pyomyositis^[107]^[108]^[109]^[110]	Acute or chronic	Days to weeks	Dull aching or throbbing	Variable	-	+	+/-	-	-	-	-	-	-	-	-	-	-	CBC Demonstrates leukocytosis ESR Elevated Serum creatine kinase and aldolase Normal Blood culture Typically negative Culture and sensitivity May include a positive gram stain	MRI Can differentiate between osteomyelitis and pyomyositis by demonstrating early muscle inflammation or abscess formation CT May demonstrate hypertrophy of muscles and/or effacement of fatty plane An enhancement in contrast may indicate abscess formation Ultrasound Useful in determining specific muscle involvement Gallium scan Useful in detecting early muscle pathology	Infectious myositis was once considered a tropical disease, however with the emergence of HIV is now prevalent in western societies too
	Rheumatoid arthritis^[111]^[112]^[113]	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 rhuematoid 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
	Traumatic aortic rupture^[114]^[115]	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 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
	Waterhouse-Friderichsen syndrome^[116]^[117]	Acute	Minutes to hours	Sudden, severe, sharp	Back and/or flanks	-	+	+/-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	CBC May show decreased hemotocrit, leukocytosis and rarely, eosinophilia Serum electrolytes Hyponatremia Hyperkalemia Hypercalcemia Blood urea nitrogen Elevated Creatinine Elevated Plasma glucose Hypoglycemia Serum cortisol Decreased Plasma ACTH, Elevated	CT Shows adrenal enlargement or adrenal aymmetry	Short cosyntropin (Cortrosyn) stimulation test confirms the diagnosis
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	Lab findings	Imaging
Tumors	Ewing's sarcoma^[118]^[119]^[120]	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 elvated 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
	Langerhans cell histiocytosis^[121]^[122]^[123]^[123](eosinophilic granulomas)	Chronic	Months to years	Dull aching	Variable	-	+/-	+/-	-	-	-	-	-	-	-	-	-	-	Tests used to rule out other pathologies; CBC Reticulocyte count may be increased Positive or negative direct and indirect Coombs test Immunoglobulin levels may be elevated ESR May be elevated LFT May demonstrate elevations in total protein, albumin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase Elevations may mean liver cirrhosis Urine analysis Decrease in urine osmolality may indicate diabetes insipidus	Radiography Single or multiple osteolytic lesions may be noted CT To identify abnormalities of the hypothalamic and/or pituitary region MRI To identify abnormalities of the hypothalamic and/or pituitary region PET - FDG More sensitive than CT or MRI to active disease
	Leukemia^[124]^[125]^[126]^[127]	Acute or chronic	Weeks to years	Aching	Variable	-	+/-	+/-	-	-	-	+	-	-	-	-	-	-	CBC Mature or immature leukocytosis Coagulation study May demonstrate elevated prothrombin time, decreasing fibrinogen level, and presence of fibrin split products Peripheral blood smear May demonstrate blasts, schistocytes, auer rods, and mature lymphocytosis Blood chemistry profile May demonstrate tumor lysis syndrome through elevated LDH and uric acid Blood culture To rule out infection	Typically no routine imaging studies, cytogenetic and flow cytometries aid diagnosis	Acute and chronic, lymphocytic and myeloid diagnoses are based on the presence and type of blast or mature cell
	Lymphoma^[128]^[129]^[130]^[131]	Chronic	Months to years	Aching	Variable	-	+/-	+/-	-	-	-	+	-	-	-	-	-	-	Typically no specific lab findings, however, the following routine tests are performed; CBC Serum chemistry studies, including LDH Serum beta2-microglobulin level HIV serology	Radiography May demonstrate hilar or mediastinal adenopathy Pleural or pericardial effusion Parenchymal involvement Bulky mediastinal mass CT May demonstrate enlarged lymph nodes Hepatosplenomegaly Filling defects in visceral organs Bone scan Useful in those with elevated alkaline phosphatase Gallium scan May show increased uptake MRI Signal intensity changes are noted in those with bone marrow or muscular involvement PET - FDG To distinguish between viable, active tumors and necrosis To detect early recurrence Ultrasound Useful if primary lesion is in testis	Hodgkin's lymphoma is usually focal and characterized by Reed-sternberg cells Non - hodgkin's lymphoma tends to be multifocal Biopsy provides ultimate diagnosis
	Neurofibroma^[132]	Chronic^[133]^[134]	Weeks to years	Aching, pressure	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-	Molecular sequencing Used to detect neurofibromin gene Urine analysis Used to detect free catecholamine and their metabolites in suspected pheochromocytoma	Radiography Bowing of bones Medullary destruction MRI and CT Used to determine neurologic pathologies May demonstrate unidentified bright objects in brain scans May demonstrate optic nerve and optic chiasma involvement Bilateral acoustic neuroma is noted in neurofibromatosis type 2 PET - FDG Used to determine staging	Marfanoid habitus may be noted in neurfibromatosis type 1
	Osteoblastoma^[135]^[136]^[137]	Chronic	Weeks to years	Dul aching	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings are noted	Radiography May demonstrate a well-circumscribed radiolucent tumor in cortex Thin shell of peripheral new bone distinct from soft tissue > 2cm in diameter No associated reactive zone CT and MRI May demonstrate size and extent of tumor relative to surrounding soft tissue Bone scan Demonstrates cortical activity within the bone Angiography Demonstrates the vascularity of the tumor	Presents in third decade of life Pain is not relieved by NSAIDs
	Osteoid osteoma^[138]^[139]^[135]	Chronic	Years	Dull aching	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-	Serum chemistry study High levels of prostaglandin metaboliteshave been linked with osteoid osteomas	Radiography May demonstrate sclerosis around a radiolucent nidus CT Demonstrates the margins of the nidus and calcifications present MRI Useful only in a non-calcified nidus Radionuclide scan Demonstrates increased uptake in diseased bone Arteriography Used a last resort when other imaging has been unfruitful Demonstrates 2 phases, early arterial phase, late arterial phase and venous phase	Pain is relieved by use of NSAIDs
	Osteosarcoma^[140]^[141]^[142]^[143]	Chronic	Weeks to years	Severe, sharp	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings Elevated LDH and alkaline phosphatase may suggest pulmonary metastasis	Radiography May demonstrate an osteolytic or osteoblastic lesion Elevation of the periosteum may be noted, and is known as "Codman's triangle" Tumor spread to periosteum is known as "sunburst" sign CT Chest CT is done to rule out pulmonary involvement May also demonstrate the margins and extent of tumor MRI Useful in detection of soft tissue involvement Bone scan Increased uptake is noted in regions of metastasis Technetium-99 - methylene diphosphonate is usually used	Cardiac function should be assessed before the use of doxorubicin or daunorubicin
	Multiple myeloma^[144]^[145]	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
	Prostate cancer^[146]^[147]	Chronic	Months to years	Severe, sharp	Lower abdomen, hips, groin and legs	-	+/-	+/-	-	-	-	+/-	-	-	-	-	-	-	PSA Detection is helpful in diagnosis, usually > 10 ng/ml Acid and alkaline phosphtase Useful in detecting metasstasis Serurm creatinine and LFT Useful in detecting metasstasis Urine analysis May detect hematuria or infection	Ultrasound Transrectal biopsy transrectal ultrasound may demonstrate hypoechoicity MRI May be used to guide biopsy	PSA and DRE are gold standard for screening
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	Lab findings	Imaging
Muscle-related	Abnormal posturing^[148]^[149]^[150]^[151]	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
	Muscle spasm^[152]^[153]	Acute	Days, weeks, months	Aching	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-	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
	Pyriformis syndrome^[154]^[155]	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	Lab findings	Imaging
Miscellaneous	Chronic fatigue syndrome^[156]^[157]^[158]	Chronic	Years	Dull aching	Variable	+/-	-	-	+/-	+/-	-	-	-	-	-	-	-	-	Typically no specific lab findings, however, serology may be somewhat specific and demonstrate; Elevated IgM and/or IgG in coxsackievirus B titer Elevated IgM and/or IgG human herpesvirus 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^[159]^[160]^[160]	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 hyporpituitarism 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
	Dysmenorrhea^[161]^[162]	Acute	3 - 7 days	Burning, dull aching or severe	Groin, hips, legs	-	-	-	+/-	+/-	-	-	-	-	-	-	-	-	Typically no specific lab findings Lab tests are done to rule out organic causes, and include; CBC Infection (leukocytosis) or malignancy STD panel Gonorrhea, chlamydia, and PID Beta - Human chorionic gonadotropin Elevated in pregnancy ESR Elevated in subacute salpingitis Urine analysis To rule out urinary tract infection Stool guaiac test To rule out gastraintestinal bleeding	Ultrasound May reveal endometriosis as complex mass with specks Ectopic pregnancy Ovarian cysts Fibroids Intrauterine contraceptive device Hysterosalpingography May demonstrate endometrial polyps Leiomyomas Congenital abnormalities of the uterus IVP May demonstrate a uterine malformation CT May demonstrate ovarian torsion MRI May detect adenomyosis Submucous myomas	Laparoscopy, hysteroscopy, and dilatation and curettage are useful in diagnosis and therapy
	Herpes zoster^[163]^[164]^[165]	Acute or chronic	Variable	Severe, stabbing, electric-like	Dermatomal	-	+/-	+/-	+/-	+/-	+/-	+/-	-	+/-	-	-	-	-	Tzanck smear May demonstrate multinucleated giant cells Direct fluorescent antibody test and/or PCR Allows for differentiation between HSV and VZV	Typically no routine imaging MRI Used to exclude myelopathy or encephalopathy Lumbar puncture and cerebrospinal fluid analysis In cases of suspected meningitis, increased protein and pleocytosis will be noted
	Pregnancy^[166]^[167]^[168]^[169]^[170]	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^[171]^[172]^[173]	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
	Syringomyelia^[174]^[175]^[176]	Chronic	Years	Dull aching	Variable	+/-	+/-	-	+/-	+/-	-	-	-	-	-	-	-	-
	Trauma^[177]	Acute or chronic	Variable	Severe, sharp to dull aching	Variable	+/-	-	-	-	+/-	+/-	-	+/-	+/-	-	-	+/-	+/-
	Ureteropelvic junction obstruction^[178]^[179]^[180]	Acute	Hours to days	Dull aching	Groin, hips, legs	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	+/-	-

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@@ Line 2,475: / Line 2,475: @@
 |<nowiki>-</nowiki>
 |<nowiki>-</nowiki>
-|
+|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
 |
 |