Back pain differential diagnosis: Difference between revisions

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Revision as of 23:10, 30 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		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	+/-	-	-	+/-	+/-	+/-	-	+/-	+/-	-	-	+/-	-
	Vertebral osteomyelitis^[64]^[65]^[66]	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	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	-	+	+/-	-	+	-	-	-	-	-	-	-	-
	Cholelithiasis^[78]^[79]	Acute or subacute	Minutes or hours	Sharp	Tip of right shoulder	-	+/-	+/-	-	+	-	+/-	-	-	-	-	-	-
	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	-	+/-	+/-	-	-	-	-	-	-	-	-	-	-
	Endocarditis^[85]^[86]^[87]	Acute or subacute	Variable	Discomfort in the chest	Jaw and arms	-	+/-	+/-	-	+/-	+/-	-	-	-	+/-	+	-	-
	Myalgia^[88]^[89]^[90]	Chronic	Years	Dull aching	Variable	+/-	+/-	+/-	+/-	-	-	-	-	-	-	-	-	-			May be associated with Hepatitis C and Lyme disease
	Nephrolithiasis^[91]^[92]^[93]	Acute	Hours	Severe, sharp	Abdomen, hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-
	Pancreatitis^[94]^[95]^[96]	Acute or chronic	Variable	Severe, sharp	Abdomen	-	+/-	+/-	-	+	+/-	+/-	-	-	-	-	-	-
	Pelvic inflammatory disease^[97]^[98]^[99]	Acute or chronic	Variable	Dullaching or throbbing	Hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-
	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	-	+	+	+/-	+/-	+/-	+/-	-	-	-	-	-	-
	Pyomyositis^[107]^[108]^[109]^[110]	Acute or chronic	Days to weeks	Dull aching or throbbing	Variable	-	+	+/-	-	-	-	-	-	-	-	-	-	-
	Rheumatoid arthritis^[111]^[112]^[113]	Chronic	Years	Severe, aching	Variable	+	-	-	-	-	-	+/-	-	-	-	-	-	-
	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	+/-	+/-	+/-	-	-	-	+	-	-	-	-	-	-
	Langerhans cell histiocytosis^[121]^[122]^[123]^[123](eosinophilic granulomas)	Chronic	Months to years	Dull aching	Variable	-	+/-	+/-	-	-	-	-	-	-	-	-	-	-
	Leukemia^[124]^[125]^[126]^[127]	Acute or chronic	Weeks to years	Aching	Variable	-	+/-	+/-	-	-	-	+	-	-	-	-	-	-
	Lymphoma^[128]^[129]^[130]^[131]	Chronic	Months to years	Aching	Variable	-	+/-	+/-	-	-	-	+	-	-	-	-	-	-
	Neurofibroma^[132]	Chronic^[133]^[134]	Weeks to years	Aching, pressure	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-
	Osteoblastoma^[135]^[136]^[137]	Chronic	Weeks to years	Dul aching	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-
	Osteoid osteoma^[138]^[139]^[135]	Chronic	Years	Dull aching	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-
	Osteosarcoma^[140]^[141]^[142]^[143]	Chronic	Weeks to years	Severe, sharp	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-
	Multiple myeloma^[144]^[145]	Chronic	Years	Dull aching	Hips, groin and legs	+/-	+/-	+/-	-	-	-	+/-	-	-	-	-	+/-	-
	Prostate cancer^[146]^[147]	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	Lab findings	Imaging
Muscle-related	Abnormal posturing^[148]^[149]^[150]^[151]	Chronic	Years	Dull aching	Shoulders, arms, hips, legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-
	Muscle spasm^[152]^[153]	Acute	Days, weeks, months	Aching	Variable	-	-	-	-	-	-	-	-	-	-	-	-	-
	Pyriformis syndrome^[154]^[155]	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	Lab findings	Imaging
Miscellaneous	Chronic fatigue syndrome^[156]^[157]^[158]	Chronic	Years	Dull aching	Variable	+/-	-	-	+/-	+/-	-	-	-	-	-	-	-	-
	Depression^[159]^[160]^[160]	Chronic	Months to years	Severe to mild aching	Variable	+/-	-	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-
	Herpes zoster^[161]^[162]^[163]	Acute or chronic	Variable	Severe, stabbing, electric-like	Dermatomal	-	+/-	+/-	+/-	+/-	+/-	+/-	-	+/-	-	-	-	-
	Pregnancy^[164]^[165]^[166]^[167]^[168]	Chronic	Pregnancy term	Dull aching	Groin, hips, legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-
	Dysmenorrhea^[169]^[170]	Acute	3 - 7 days	Burning, dull aching or severe	Groin, hips, legs	-	-	-	+/-	+/-	-	-	-	-	-	-	-	-
	Sickle cell anemia^[171]^[172]^[173]	Acute or chronic	Variable	Severe, sharp	Variable	+/-	+	+/-	-	-	-	-	-	-	-	-	-	-
	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	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	+/-	-

References

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@@ Line 815: / Line 815: @@
 |<nowiki>+/-</nowiki>
 |<nowiki>-</nowiki>
-|
+|*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]]<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>
@@ Line 837: / Line 840: @@
 |<nowiki>+/-</nowiki>
 |<nowiki>+/-</nowiki>
-|
+|*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]]<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>
@@ Line 859: / Line 866: @@
 |<nowiki>+/-</nowiki>
 |<nowiki>+/-</nowiki>
-|
+|*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
 |-
 ![[Compression fracture|Vertebral compression fracture]]<ref name="pmid10692972">{{cite journal |vauthors=Genant HK, Cooper C, Poor G, Reid I, Ehrlich G, Kanis J, Nordin BE, Barrett-Connor E, Black D, Bonjour JP, Dawson-Hughes B, Delmas PD, Dequeker J, Ragi Eis S, Gennari C, Johnell O, Johnston CC, Lau EM, Liberman UA, Lindsay R, Martin TJ, Masri B, Mautalen CA, Meunier PJ, Khaltaev N |title=Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis |journal=Osteoporos Int |volume=10 |issue=4 |pages=259–64 |date=1999 |pmid=10692972 |doi= |url=}}</ref><ref name="pmid10994823">{{cite journal |vauthors=Vogt TM, Ross PD, Palermo L, Musliner T, Genant HK, Black D, Thompson DE |title=Vertebral fracture prevalence among women screened for the Fracture Intervention Trial and a simple clinical tool to screen for undiagnosed vertebral fractures. Fracture Intervention Trial Research Group |journal=Mayo Clin. Proc. |volume=75 |issue=9 |pages=888–96 |date=September 2000 |pmid=10994823 |doi= |url=}}</ref><ref name="pmid12208381">{{cite journal |vauthors=Papaioannou A, Watts NB, Kendler DL, Yuen CK, Adachi JD, Ferko N |title=Diagnosis and management of vertebral fractures in elderly adults |journal=Am. J. Med. |volume=113 |issue=3 |pages=220–8 |date=August 2002 |pmid=12208381 |doi= |url=}}</ref>