Back pain differential diagnosis: Difference between revisions

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Revision as of 15:10, 22 March 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

Classification of pain in the back based on etiology	Diease	Clinical Manifestation													Diagnosis
		Symptoms									Signs				Lab findings	Imaging
		Onset	Duration	Quality of pain	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Weight loss	Motor weakness	Sensory deficit	Bowel or bladder dysfunction	Horner's syndrome	Lab findings	Imaging
Vascular	Aortic dissection
	Aortic aneurysm - Abdominal aortic aneurysm - Thoracic aortic aneurysm
	Chronic stable angina
	Pulmonary embolism
	Traumatic aortic rupture
	Retroperitoneal hematoma
	Waterhouse Friderichsen syndrome
Neurological	Arachnoiditis
	Cauda equina syndrome
	Epidural abscess
	Radiculopathy
	Sciatica
	Spinal cord compression - Thoracic spine - Lumbar spine
Bone	Ankylosing spondylitis
	Bertolotti's syndrome (Lumbosacral transitional vertebrae)
	Chronic recurrent focal osteomyelitis
	Cervical fracture
	Degenerative disc disease
	Disc herniation
	Discitis
	Hyperkyphosis
	Osteoarthritis
	Sacroiliac joint dysfunction
	Sacroilitis
	Scheuermann (juvenile) kyphosis
	Scoliosis
	Spinal stenosis
	Spondylosis
	Vertebral compression fracture
	Vertebral osteomyelitis
Non-spinal infections	Pyomyositis
	Pyelonephritis
	Nephrolithiasis
	Pelvic inflammatory disease
	Pneumonia
	Endocarditis
	Myalgia
	Cystitis
	Cholelithiasis
	Appendicitis
	Inflammatory arthritis
Tumors	Osteoid osteoma
	Osteoblastoma
	Ewing sarcoma
	Osteosarcoma
	Lymphoma
	Prostate cancer
	Neurofibroma
	Leukemia
	Langerhan cell histocytosis (eosinophilic granulomas)
Muscle-related	Pyriformis syndrome
	Muscle spasm
	Abnormal posture
Miscellaneous	Trauma
	Pregnancy
	Premenstrual syndrome
	Herpes zoster
	Sickle cell anemia
	Syringomyelia
	Ureteropelvic junction obstruction
	Chronic pain syndrome
	Psychologic distress

References

↑ 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.
↑ ^2.0 ^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.
↑ ^3.0 ^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.
↑ 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.
↑ 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.
↑ Underwood MR, Dawes P (November 1995). "Inflammatory back pain in primary care". Br. J. Rheumatol. 34 (11): 1074–7. PMID 8542211.
↑ "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.
↑ Ropper AH, Zafonte RD (March 2015). "Sciatica". N. Engl. J. Med. 372 (13): 1240–8. doi:10.1056/NEJMra1410151. PMID 25806916.
↑ 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.
↑ 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.
↑ 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.
↑ Potter NA, Rothstein JM (November 1985). "Intertester reliability for selected clinical tests of the sacroiliac joint". Phys Ther. 65 (11): 1671–5. PMID 2932746.
↑ 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.
↑ 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.
↑ 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.
↑ 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.
↑ 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.

Template:WikiDoc Sources

[pmid21282698-1] 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.

[pmid9270576-2] 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.

[pmid2967893-3] 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.

[pmid24150427-4] 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.

[pmid12353946-5] 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.

[pmid8542211-6] Underwood MR, Dawes P (November 1995). "Inflammatory back pain in primary care". Br. J. Rheumatol. 34 (11): 1074–7. PMID 8542211.

[pmid7987418-7] "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.

[pmid25806916-8] Ropper AH, Zafonte RD (March 2015). "Sciatica". N. Engl. J. Med. 372 (13): 1240–8. doi:10.1056/NEJMra1410151. PMID 25806916.

[pmid25844995-9] 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.

[pmid15062719-10] 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.

[pmid20596735-11] 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.

[pmid2932746-12] Potter NA, Rothstein JM (November 1985). "Intertester reliability for selected clinical tests of the sacroiliac joint". Phys Ther. 65 (11): 1671–5. PMID 2932746.

[pmid7326071-13] 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.

[pmid10534797-14] 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.

[pmid12147007-15] 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.

[pmid17304687-16] 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.

[pmid26484005-17] 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.

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@@ Line 31: / Line 31: @@
 * [[Degenerative disc disease]]
 * [[Depression]]
-* [[Discopathy]]
 * [[Osteoarthritis]]
 * [[Pregnancy]]
@@ Line 43: / Line 42: @@
 {| class="wikitable"
-! rowspan="3"  style="background:#4479BA; color: #FFFFFF;" align="center" |Classification of pain in the back based on etiology
+! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Classification of pain in the back based on etiology
-! rowspan="3"  style="background:#4479BA; color: #FFFFFF;" align="center" |Diease
+! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Diease
-! colspan="13"  style="background:#4479BA; color: #FFFFFF;" align="center"|Clinical Manifestation
+! colspan="13" style="background:#4479BA; color: #FFFFFF;" align="center" |Clinical Manifestation
-! colspan="2"  style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis
+! colspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Diagnosis
-! rowspan="3"  style="background:#4479BA; color: #FFFFFF;" align="center" |Comments
+! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Comments
 |-
-! colspan="9"  style="background:#4479BA; color: #FFFFFF;" align="center" |Symptoms
+! colspan="9" style="background:#4479BA; color: #FFFFFF;" align="center" |Symptoms
-! colspan="4"  style="background:#4479BA; color: #FFFFFF;" align="center" |Signs
+! colspan="4" style="background:#4479BA; color: #FFFFFF;" align="center" |Signs
-! rowspan="2"  style="background:#4479BA; color: #FFFFFF;" align="center" |Lab findings
+! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Lab findings
-! rowspan="2"  style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
+! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" |Imaging
 |-
 ! style="background:#4479BA; color: #FFFFFF;" align="center" |Onset
@@ Line 68: / Line 67: @@
 ! style="background:#4479BA; color: #FFFFFF;" align="center" |Horner's syndrome
 |-
-! rowspan="7" style="background:#4479BA; color: #FFFFFF;" align="center"|Vascular
+! rowspan="7" style="background:#4479BA; color: #FFFFFF;" align="center" |Vascular
-!Aortic dissection
+![[Aortic dissection]]
 |
 |
@@ Line 87: / Line 86: @@
 |
 |-
-!Aortic aneurysm
+![[Aortic aneurysm]]
-- Abdominal aneurysm
+- [[Abdominal aortic aneurysm]]
-- Thoracic aneurysm
+- [[Thoracic aortic aneurysm]]
 |
 |
@@ Line 108: / Line 107: @@
 |
 |-
-!Adrenal haemorrhgage
+![[Chronic stable angina]]
 |
 |
@@ Line 126: / Line 125: @@
 |
 |-
-!Chronic stable angina
+![[Pulmonary embolism]]
 |
 |
@@ Line 144: / Line 143: @@
 |
 |-
-!Pulmonary embolism
+![[Traumatic aortic rupture]]
 |
 |
@@ Line 162: / Line 161: @@
 |
 |-
-!Traumatic aortic rupture
+![[Retroperitoneal hematoma]]
 |
 |
@@ Line 180: / Line 179: @@
 |
 |-
-!Retroperitoneal hematoma
+!Waterhouse Friderichsen syndrome
 |
 |
@@ Line 198: / Line 197: @@
 |
 |-
-! rowspan="6" style="background:#4479BA; color: #FFFFFF;" align="center"|Neurological
+! rowspan="6" style="background:#4479BA; color: #FFFFFF;" align="center" |Neurological
-!Arachnoiditis
+![[Arachnoiditis]]
 |
 |
@@ Line 217: / Line 216: @@
 |
 |-
-!Spinal cord compression
+![[Cauda equina syndrome]]
-- Thoracic spine
-- Lumbar spine
 |
 |
@@ Line 239: / Line 234: @@
 |
 |-
-!Cauda equina syndrome
+![[Epidural abscess]]
 |
 |
@@ Line 257: / Line 252: @@
 |
 |-
-!Radiculopathy
+![[Radiculopathy]]
 |
 |
@@ Line 275: / Line 270: @@
 |
 |-
-!Epidural abscess
+![[Sciatica]]
 |
 |
@@ Line 293: / Line 288: @@
 |
 |-
-!Sciatica
+![[Spinal cord compression]]
+- Thoracic spine
+- Lumbar spine
 |
 |
@@ Line 311: / Line 310: @@
 |
 |-
-! rowspan="18" style="background:#4479BA; color: #FFFFFF;" align="center"|Bone
+| rowspan="17" |Bone
-!Discitis/discopathy
+![[Ankylosing spondylitis]]
 |
 |
@@ Line 330: / Line 329: @@
 |
 |-
-!Vertebral osteomyelitis
+![[Bertolotti's syndrome]] (Lumbosacral transitional vertebrae)
 |
 |
@@ Line 348: / Line 347: @@
 |
 |-
-!Septic sacroilitis
+![[Osteomyelitis|Chronic recurrent focal osteomyelitis]]
 |
 |
@@ Line 366: / Line 365: @@
 |
 |-
-!Vertebral compression fracture
+![[Cervical fracture]]
 |
 |
@@ Line 384: / Line 383: @@
 |
 |-
-!Spinal stenosis
+![[Degenerative disc disease]]
 |
 |
@@ Line 402: / Line 401: @@
 |
 |-
-!Osteoarthritis
+![[Spinal disc herniation|Disc herniation]]
 |
 |
@@ Line 420: / Line 419: @@
 |
 |-
-!Ankylosing spondylitis
+![[Discitis]]
 |
 |
@@ Line 438: / Line 437: @@
 |
 |-
-!Chronic recurrent focal osteomyelitis
+!Hyperkyphosis
 |
 |
@@ Line 456: / Line 455: @@
 |
 |-
-!Scoliosis
+![[Osteoarthritis]]
 |
 |
@@ Line 474: / Line 473: @@
 |
 |-
-!Hyperkyphosis
+!Sacroiliac joint dysfunction
 |
 |
@@ Line 492: / Line 491: @@
 |
 |-
-!Spondylosis
+!Sacroilitis
--Spondylolisthesis
 |
 |
@@ Line 511: / Line 509: @@
 |
 |-
-!Cervical fracture
+![[Kyphosis|Scheuermann (juvenile) kyphosis]]
 |
 |
@@ Line 529: / Line 527: @@
 |
 |-
-!Scheuermann (juvenile) kyphosis
+![[Scoliosis]]
 |
 |
@@ Line 547: / Line 545: @@
 |
 |-
-!Disc herniation
+![[Spinal stenosis]]
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|
-|-
-!Sacroiliac joint dysfunction
 |
 |
@@ Line 583: / Line 563: @@
 |
 |-
-!Bertolotti's syndrome (Lumbosacral transitional vertebrae)
+![[Spondylosis]]
 |
 |
@@ Line 601: / Line 581: @@
 |
 |-
-!Degenerative disc disease
+![[Compression fracture|Vertebral compression fracture]]
 |
 |
@@ Line 619: / Line 599: @@
 |
 |-
-!Osteoarthritis
+![[Vertebral osteomyelitis]]
 |
 |
@@ Line 637: / Line 617: @@
 |
 |-
-! rowspan="11" style="background:#4479BA; color: #FFFFFF;" align="center"|Non-spinal infections
+! rowspan="11" style="background:#4479BA; color: #FFFFFF;" align="center" |Non-spinal infections
 !Pyomyositis
 |
@@ Line 836: / Line 816: @@
 |
 |-
-! rowspan="9" style="background:#4479BA; color: #FFFFFF;" align="center"|Tumors
+! rowspan="9" style="background:#4479BA; color: #FFFFFF;" align="center" |Tumors
 !Osteoid osteoma
 |
@@ Line 999: / Line 979: @@
 |
 |-
-! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center"|Muscle-related
+! rowspan="3" style="background:#4479BA; color: #FFFFFF;" align="center" |Muscle-related
 !Pyriformis syndrome
 |
@@ Line 1,054: / Line 1,034: @@
 |
 |-
-! rowspan="9" style="background:#4479BA; color: #FFFFFF;" align="center"|Miscellaneous
+! rowspan="9" style="background:#4479BA; color: #FFFFFF;" align="center" |Miscellaneous
 !Trauma
 |