Back pain differential diagnosis: Difference between revisions

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! rowspan="17" align="center" style="background:#4479BA; color: #FFFFFF;" |Bone
! rowspan="17" align="center" style="background:#4479BA; color: #FFFFFF;" |Bone
![[Ankylosing spondylitis]]<ref name="pmid20882310">{{cite journal |vauthors=Roussou E, Sultana S |title=Spondyloarthritis in women: differences in disease onset, clinical presentation, and Bath Ankylosing Spondylitis Disease Activity and Functional indices (BASDAI and BASFI) between men and women with spondyloarthritides |journal=Clin. Rheumatol. |volume=30 |issue=1 |pages=121–7 |date=January 2011 |pmid=20882310 |doi=10.1007/s10067-010-1581-5 |url=}}</ref>
![[Ankylosing spondylitis]]<ref name="pmid20882310">{{cite journal |vauthors=Roussou E, Sultana S |title=Spondyloarthritis in women: differences in disease onset, clinical presentation, and Bath Ankylosing Spondylitis Disease Activity and Functional indices (BASDAI and BASFI) between men and women with spondyloarthritides |journal=Clin. Rheumatol. |volume=30 |issue=1 |pages=121–7 |date=January 2011 |pmid=20882310 |doi=10.1007/s10067-010-1581-5 |url=}}</ref><ref name="pmid26768406">{{cite journal |vauthors=Deodhar A, Strand V, Kay J, Braun J |title=The term 'non-radiographic axial spondyloarthritis' is much more important to classify than to diagnose patients with axial spondyloarthritis |journal=Ann. Rheum. Dis. |volume=75 |issue=5 |pages=791–4 |date=May 2016 |pmid=26768406 |doi=10.1136/annrheumdis-2015-208852 |url=}}</ref>
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![[Cervical fracture]]<ref name="pmid23940857">{{cite journal |vauthors=Nelson DW, Martin MJ, Martin ND, Beekley A |title=Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma |journal=J Trauma Acute Care Surg |volume=75 |issue=1 |pages=135–9 |date=July 2013 |pmid=23940857 |doi= |url=}}</ref>
![[Cervical fracture]]<ref name="pmid23940857">{{cite journal |vauthors=Nelson DW, Martin MJ, Martin ND, Beekley A |title=Evaluation of the risk of noncontiguous fractures of the spine in blunt trauma |journal=J Trauma Acute Care Surg |volume=75 |issue=1 |pages=135–9 |date=July 2013 |pmid=23940857 |doi= |url=}}</ref><ref name="pmid18783909">{{cite journal |vauthors=Greenbaum J, Walters N, Levy PD |title=An evidenced-based approach to radiographic assessment of cervical spine injuries in the emergency department |journal=J Emerg Med |volume=36 |issue=1 |pages=64–71 |date=January 2009 |pmid=18783909 |doi=10.1016/j.jemermed.2008.01.014 |url=}}</ref>
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![[Degenerative disc disease]]<ref name="pmid2954221">{{cite journal |vauthors=Deyo RA, Tsui-Wu YJ |title=Descriptive epidemiology of low-back pain and its related medical care in the United States |journal=Spine |volume=12 |issue=3 |pages=264–8 |date=April 1987 |pmid=2954221 |doi= |url=}}</ref>
![[Degenerative disc disease]]<ref name="pmid2954221">{{cite journal |vauthors=Deyo RA, Tsui-Wu YJ |title=Descriptive epidemiology of low-back pain and its related medical care in the United States |journal=Spine |volume=12 |issue=3 |pages=264–8 |date=April 1987 |pmid=2954221 |doi= |url=}}</ref><ref name="pmid9523780">{{cite journal |vauthors=Slipman CW, Sterenfeld EB, Chou LH, Herzog R, Vresilovic E |title=The predictive value of provocative sacroiliac joint stress maneuvers in the diagnosis of sacroiliac joint syndrome |journal=Arch Phys Med Rehabil |volume=79 |issue=3 |pages=288–92 |date=March 1998 |pmid=9523780 |doi= |url=}}</ref>
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![[Spinal disc herniation|Disc herniation]]<ref name="pmid9670842">{{cite journal |vauthors=Hay MC |title=Anatomy of the lumbar spine |journal=Med. J. Aust. |volume=1 |issue=23 |pages=874–6 |date=June 1976 |pmid=967084 |doi= |url=}}</ref>
![[Spinal disc herniation|Disc herniation]]<ref name="pmid9670842">{{cite journal |vauthors=Hay MC |title=Anatomy of the lumbar spine |journal=Med. J. Aust. |volume=1 |issue=23 |pages=874–6 |date=June 1976 |pmid=967084 |doi= |url=}}</ref><ref name="pmid12152441">{{cite journal |vauthors=Levin KH |title=Electrodiagnostic approach to the patient with suspected radiculopathy |journal=Neurol Clin |volume=20 |issue=2 |pages=397–421, vi |date=May 2002 |pmid=12152441 |doi= |url=}}</ref>
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![[Discitis]]<ref name="pmid8235857">{{cite journal |vauthors=Hamanishi C, Tanaka S |title=Dorsal root ganglia in the lumbosacral region observed from the axial views of MRI |journal=Spine |volume=18 |issue=13 |pages=1753–6 |date=October 1993 |pmid=8235857 |doi= |url=}}</ref>
![[Discitis]]<ref name="pmid8235857">{{cite journal |vauthors=Hamanishi C, Tanaka S |title=Dorsal root ganglia in the lumbosacral region observed from the axial views of MRI |journal=Spine |volume=18 |issue=13 |pages=1753–6 |date=October 1993 |pmid=8235857 |doi= |url=}}</ref><ref name="pmid25734175">{{cite journal |vauthors=Gupta A, Kowalski TJ, Osmon DR, Enzler M, Steckelberg JM, Huddleston PM, Nassr A, Mandrekar JM, Berbari EF |title=Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 patients |journal=Open Forum Infect Dis |volume=1 |issue=3 |pages=ofu107 |date=December 2014 |pmid=25734175 |pmc=4324221 |doi=10.1093/ofid/ofu107 |url=}}</ref>
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!Hyperkyphosis<ref name="pmid4419577">{{cite journal |vauthors=Milne JS, Lauder IJ |title=Age effects in kyphosis and lordosis in adults |journal=Ann. Hum. Biol. |volume=1 |issue=3 |pages=327–37 |date=July 1974 |pmid=4419577 |doi= |url=}}</ref>
!Hyperkyphosis<ref name="pmid4419577">{{cite journal |vauthors=Milne JS, Lauder IJ |title=Age effects in kyphosis and lordosis in adults |journal=Ann. Hum. Biol. |volume=1 |issue=3 |pages=327–37 |date=July 1974 |pmid=4419577 |doi= |url=}}</ref><ref name="pmid15088302">{{cite journal |vauthors=Schneider DL, von Mühlen D, Barrett-Connor E, Sartoris DJ |title=Kyphosis does not equal vertebral fractures: the Rancho Bernardo study |journal=J. Rheumatol. |volume=31 |issue=4 |pages=747–52 |date=April 2004 |pmid=15088302 |doi= |url=}}</ref>
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![[Osteoarthritis]]<ref name="pmid18296075">{{cite journal |vauthors=Hawker GA, Stewart L, French MR, Cibere J, Jordan JM, March L, Suarez-Almazor M, Gooberman-Hill R |title=Understanding the pain experience in hip and knee osteoarthritis--an OARSI/OMERACT initiative |journal=Osteoarthr. Cartil. |volume=16 |issue=4 |pages=415–22 |date=April 2008 |pmid=18296075 |doi=10.1016/j.joca.2007.12.017 |url=}}</ref>
![[Osteoarthritis]]<ref name="pmid18296075">{{cite journal |vauthors=Hawker GA, Stewart L, French MR, Cibere J, Jordan JM, March L, Suarez-Almazor M, Gooberman-Hill R |title=Understanding the pain experience in hip and knee osteoarthritis--an OARSI/OMERACT initiative |journal=Osteoarthr. Cartil. |volume=16 |issue=4 |pages=415–22 |date=April 2008 |pmid=18296075 |doi=10.1016/j.joca.2007.12.017 |url=}}</ref><ref name="pmid9462165">{{cite journal |vauthors=Hurley MV, Scott DL, Rees J, Newham DJ |title=Sensorimotor changes and functional performance in patients with knee osteoarthritis |journal=Ann. Rheum. Dis. |volume=56 |issue=11 |pages=641–8 |date=November 1997 |pmid=9462165 |pmc=1752287 |doi= |url=}}</ref><ref name="pmid18203312">{{cite journal |vauthors=Sale JE, Gignac M, Hawker G |title=The relationship between disease symptoms, life events, coping and treatment, and depression among older adults with osteoarthritis |journal=J. Rheumatol. |volume=35 |issue=2 |pages=335–42 |date=February 2008 |pmid=18203312 |doi= |url=}}</ref>
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* Boucard's and Heberden's  nodes
* Boucard's and Heberden's  nodes
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!Sacroiliac joint dysfunction<ref name="pmid23409086">{{cite journal |vauthors=Betti L, von Cramon-Taubadel N, Manica A, Lycett SJ |title=Global geometric morphometric analyses of the human pelvis reveal substantial neutral population history effects, even across sexes |journal=PLoS ONE |volume=8 |issue=2 |pages=e55909 |date=2013 |pmid=23409086 |pmc=3567032 |doi=10.1371/journal.pone.0055909 |url=}}</ref>
!Sacroiliac joint dysfunction<ref name="pmid23409086">{{cite journal |vauthors=Betti L, von Cramon-Taubadel N, Manica A, Lycett SJ |title=Global geometric morphometric analyses of the human pelvis reveal substantial neutral population history effects, even across sexes |journal=PLoS ONE |volume=8 |issue=2 |pages=e55909 |date=2013 |pmid=23409086 |pmc=3567032 |doi=10.1371/journal.pone.0055909 |url=}}</ref><ref name="pmid17117004">{{cite journal |vauthors=Foley BS, Buschbacher RM |title=Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment |journal=Am J Phys Med Rehabil |volume=85 |issue=12 |pages=997–1006 |date=December 2006 |pmid=17117004 |doi=10.1097/01.phm.0000247633.68694.c1 |url=}}</ref>
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!Sacroilitis<ref name="pmid17117004">{{cite journal |vauthors=Foley BS, Buschbacher RM |title=Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment |journal=Am J Phys Med Rehabil |volume=85 |issue=12 |pages=997–1006 |date=December 2006 |pmid=17117004 |doi=10.1097/01.phm.0000247633.68694.c1 |url=}}</ref>
!Sacroilitis<ref name="pmid17117004">{{cite journal |vauthors=Foley BS, Buschbacher RM |title=Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment |journal=Am J Phys Med Rehabil |volume=85 |issue=12 |pages=997–1006 |date=December 2006 |pmid=17117004 |doi=10.1097/01.phm.0000247633.68694.c1 |url=}}</ref><ref name="pmid6600615">{{cite journal |vauthors=Carette S, Graham D, Little H, Rubenstein J, Rosen P |title=The natural disease course of ankylosing spondylitis |journal=Arthritis Rheum. |volume=26 |issue=2 |pages=186–90 |date=February 1983 |pmid=6600615 |doi= |url=}}</ref>
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![[Kyphosis|Scheuermann (juvenile) kyphosis]]<ref name="pmid10393769">{{cite journal |vauthors=Lowe TG |title=Scheuermann's disease |journal=Orthop. Clin. North Am. |volume=30 |issue=3 |pages=475–87, ix |date=July 1999 |pmid=10393769 |doi= |url=}}</ref>
![[Kyphosis|Scheuermann (juvenile) kyphosis]]<ref name="pmid10393769">{{cite journal |vauthors=Lowe TG |title=Scheuermann's disease |journal=Orthop. Clin. North Am. |volume=30 |issue=3 |pages=475–87, ix |date=July 1999 |pmid=10393769 |doi= |url=}}</ref><ref name="pmid17184084">{{cite journal |vauthors=Codd PJ, Riesenburger RI, Klimo P, Slotkin JR, Smith ER |title=Vertebra plana due to an aneurysmal bone cyst of the lumbar spine. Case report and review of the literature |journal=J. Neurosurg. |volume=105 |issue=6 Suppl |pages=490–5 |date=December 2006 |pmid=17184084 |doi=10.3171/ped.2006.105.6.490 |url=}}</ref>
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![[Scoliosis]]<ref name="pmid8816647">{{cite journal |vauthors=Stirling AJ, Howel D, Millner PA, Sadiq S, Sharples D, Dickson RA |title=Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study |journal=J Bone Joint Surg Am |volume=78 |issue=9 |pages=1330–6 |date=September 1996 |pmid=8816647 |doi= |url=}}</ref>
![[Scoliosis]]<ref name="pmid8816647">{{cite journal |vauthors=Stirling AJ, Howel D, Millner PA, Sadiq S, Sharples D, Dickson RA |title=Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study |journal=J Bone Joint Surg Am |volume=78 |issue=9 |pages=1330–6 |date=September 1996 |pmid=8816647 |doi= |url=}}</ref><ref name="pmid1129452">{{cite journal |vauthors=McAlister WH, Shackelford GD |title=Classification of spinal curvatures |journal=Radiol. Clin. North Am. |volume=13 |issue=1 |pages=93–112 |date=April 1975 |pmid=1129452 |doi= |url=}}</ref><ref name="pmid4760104">{{cite journal |vauthors=Riseborough EJ, Wynne-Davies R |title=A genetic survey of idiopathic scoliosis in Boston, Massachusetts |journal=J Bone Joint Surg Am |volume=55 |issue=5 |pages=974–82 |date=July 1973 |pmid=4760104 |doi= |url=}}</ref>
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![[Spinal stenosis]]<ref name="pmid18287604">{{cite journal |vauthors=Katz JN, Harris MB |title=Clinical practice. Lumbar spinal stenosis |journal=N. Engl. J. Med. |volume=358 |issue=8 |pages=818–25 |date=February 2008 |pmid=18287604 |doi=10.1056/NEJMcp0708097 |url=}}</ref>
![[Spinal stenosis]]<ref name="pmid18287604">{{cite journal |vauthors=Katz JN, Harris MB |title=Clinical practice. Lumbar spinal stenosis |journal=N. Engl. J. Med. |volume=358 |issue=8 |pages=818–25 |date=February 2008 |pmid=18287604 |doi=10.1056/NEJMcp0708097 |url=}}</ref><ref name="pmid8600197">{{cite journal |vauthors=Ciol MA, Deyo RA, Howell E, Kreif S |title=An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations |journal=J Am Geriatr Soc |volume=44 |issue=3 |pages=285–90 |date=March 1996 |pmid=8600197 |doi= |url=}}</ref>
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![[Spondylosis]]<ref name="pmid8817777">{{cite journal |vauthors=Yabuki S, Kikuchi S |title=Positions of dorsal root ganglia in the cervical spine. An anatomic and clinical study |journal=Spine |volume=21 |issue=13 |pages=1513–7 |date=July 1996 |pmid=8817777 |doi= |url=}}</ref>
![[Spondylosis]]<ref name="pmid8817777">{{cite journal |vauthors=Yabuki S, Kikuchi S |title=Positions of dorsal root ganglia in the cervical spine. An anatomic and clinical study |journal=Spine |volume=21 |issue=13 |pages=1513–7 |date=July 1996 |pmid=8817777 |doi= |url=}}</ref><ref name="pmid2536306">{{cite journal |vauthors=Lestini WF, Wiesel SW |title=The pathogenesis of cervical spondylosis |journal=Clin. Orthop. Relat. Res. |volume= |issue=239 |pages=69–93 |date=February 1989 |pmid=2536306 |doi= |url=}}</ref>
|Chronic
|Chronic<ref name="pmid12380556">{{cite journal |vauthors=Storm PB, Chou D, Tamargo RJ |title=Surgical management of cervical and lumbosacral radiculopathies: indications and outcomes |journal=Phys Med Rehabil Clin N Am |volume=13 |issue=3 |pages=735–59 |date=August 2002 |pmid=12380556 |doi= |url=}}</ref>
|Years
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|Dull aching
|Dull aching

Revision as of 14:51, 30 March 2018

Back pain Microchapters

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Differentiating Back Pain from other Diseases

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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 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
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
Sciatica[28][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
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
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[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
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] 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
Cervical fracture[33][34] Acute Minutes to hours Severe, sharp Shoulder and arm - - - +/- - - - +/- +/- - - - +/-
Degenerative disc disease[35][36] Subacute or chronic Years Dull aching Local +/- - - - - - - +/- +/- - - +/- +/-
Disc herniation[37][38] Acute Minutes to hours Sharp,shooting Legs and hips - - - - - - - +/- +/- - - +/- -
Discitis[39][40] Chronic Years Dull aching or throbbing Local - + +/- - +/- - +/- +/- +/- - - +/- -
Hyperkyphosis[41][42] Chronic Years Dull aching Local +/- - - - - - - +/- +/- - - - -
Osteoarthritis[43][44][45] 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
 Plain films
  • 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
  • Boucard's and Heberden's nodes
Sacroiliac joint dysfunction[46][47] Chronic Years Dull aching Hips and legs +/- - - - - - - +/- +/- - - +/- -
Sacroilitis[47][48] Acute or chronic Variable Dull aching or throbbing Hips and legs +/- + +/- - - - +/- +/- +/- - - +/- -
Scheuermann (juvenile) kyphosis[49][50] Chronic Years Dull aching Shoulders and arms +/- - - - - - - - - - - - -
Scoliosis[51][52][53] Chronic Years Dull aching Shoulders, arms, hips and legs +/- - - - - - - +/- +/- - - +/- -
Spinal stenosis[54][55] Chronic Years Dull aching Hips and legs +/- - - - - - - +/- +/- - - +/- +/-
Spondylosis[56][57] Chronic[58] Years Dull aching Shoulders, arms, hips and legs +/- - - +/- - - - +/- +/- - - +/- +/-
Vertebral compression fracture[59] Acute Minutes to hours Sudden, severe, sharp Shoulders, arms, hips and legs +/- - - +/- +/- +/- - +/- +/- - - +/- -
Vertebral osteomyelitis[60] Acute Minutes to hours Sudden, severe, sharp Shoulders, arms, hips and legs +/- + +/- - +/- - - +/- +/- - - +/- -
Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Referred pain Aortic aneurysm

rupture[61][62][63] - 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[64][65][66][66][67][68] 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[69] Acute Minutes to hours Burning Umbilicus and lower right quadrant - + +/- - + - - - - - - - -
Cholelithiasis[70] Acute or subacute Minutes or hours Sharp Tip of right shoulder - +/- +/- - + - +/- - - - - - -
Chronic stable angina[71][72] 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[73] Acute Hours Burning Suprapubic - +/- +/- - - - - - - - - - -
Endocarditis[74] Acute or subacute Variable Discomfort in the chest Jaw and arms - +/- +/- - +/- +/- - - - +/- + - -
Myalgia[75] Chronic Years Dull aching Variable +/- +/- +/- +/- - - - - - - - - -
  • May be associated with Hepatitis C and Lyme disease
Nephrolithiasis[76] Acute Hours Severe, sharp Abdomen, hips, groin, legs - +/- +/- - +/- - - - - - - - -
Pancreatitis[77] Acute or chronic Variable Severe, sharp Abdomen - +/- +/- - + +/- +/- - - - - - -
Pelvic inflammatory disease[78] Acute or chronic Variable Dullaching or throbbing Hips, groin, legs - +/- +/- - +/- - - - - - - - -
Pulmonary embolism[79][80] 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[81] 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[82] Acute or chronic Variable Variable Chest, back and abdomen - + + +/- +/- +/- +/- - - - - - -
Pyomyositis[83] Acute or chronic Days to weeks Dull aching or throbbing Variable - + +/- - - - - - - - - - -
Rheumatoid arthritis[84] Chronic Years Severe, aching Variable + - - - - - +/- - - - - - -
Traumatic aortic rupture[85][86] 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[87][88] 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
Tumors Ewing's sarcoma[89] Chronic Months to years Dull aching Variable +/- +/- +/- - - - + - - - - - -
Langerhans cell histiocytosis[90](eosinophilic granulomas) Chronic Months to years Dull aching Variable - +/- +/- - - - - - - - - - -
Leukemia[91] Acute or chronic Weeks to years Aching Variable - +/- +/- - - - + - - - - - -
Lymphoma[92] Chronic Months to years Aching Variable - +/- +/- - - - + - - - - - -
Neurofibroma[93] Chronic Weeks to years Aching, pressure Variable - - - - - - - - - - - - -
Osteoblastoma[94] Chronic Weeks to years Dul aching Variable - - - - - - - - - - - - -
Osteoid osteoma[95] Chronic Years Dull aching Variable - - - - - - - - - - - - -
Osteosarcoma[96] Chronic Weeks to years Severe, sharp Variable - - - - - - - - - - - - -
Multiple myeloma[97] Chronic Years Dull aching Hips, groin and legs +/- +/- +/- - - - +/- - - - - +/- -
Prostate cancer[98] Chronic Months to years Severe, sharp Lower abdomen, hips, groin and legs - +/- +/- - - - +/- - - - - - -
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[99] Chronic Years Dull aching Shoulders, arms, hips, legs +/- - - - - - - - - - - - -
Muscle spasm[100] Acute Days, weeks, months Aching Variable - - - - - - - - - - - - -
Pyriformis syndrome[101] Chronic Years Aching Hips and legs +/- - - - - - - - - - - - -
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[102] Chronic Years Dull aching Variable +/- - - +/- +/- - - - - - - - -
Depression[103] Chronic Months to years Severe to mild aching Variable +/- - - +/- +/- +/- +/- - - - - - -
Herpes zoster[104] Acute or chronic Variable Severe, sharp, electric-like Dermatomal - +/- +/- +/- +/- +/- +/- - +/- - - - -
Pregnancy[105] Chronic Pregnancy term Dull aching Groin, hips, legs +/- - - - - - - - - - - - -
Dysmenorrhea[106] Acute 3 - 7 days Burning, dull aching or severe Groin, hips, legs - - - +/- +/- - - - - - - - -
Sickle cell anemia[107] Acute or chronic Variable Severe, sharp Variable +/- + +/- - - - - - - - - - -
Syringomyelia[108] Chronic Years Dull aching Variable +/- +/- - +/- +/- - - - - - - - -
Trauma[109] Acute or chronic Variable Severe, sharp to dull aching Variable +/- - - - +/- +/- - +/- +/- - - +/- +/-
Ureteropelvic junction obstruction[110] Acute Hours to days Dull aching Groin, hips, legs - +/- +/- +/- +/- - - - - - - +/- -

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