Back pain differential diagnosis

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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:

• Abdominal aortic aneurysm
• Adrenal hemorrhage
• Aortic dissection
• Arachnoiditis
• Cauda equina syndrome
• Cervical fracture
• Chronic stable angina
• Epidural abscess
• Pulmonary embolism
• Retroperitoneal hematoma
• Traumatic aortic rupture
• Vertebral fractures

Common Causes

• Abnormal posturing
• Degenerative disc disease
• Depression
• Osteoarthritis
• Pregnancy
• Premenstrual syndrome
• Sciatica
• Spinal disc herniation
• Spinal stenosis
• Trauma

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	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	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	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	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	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	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 - 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	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 (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	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	Acute	Minutes to hours	Severe, sharp	Shoulder and arm	-	-	-	+/-	-	-	-	+/-	+/-	-	-	-	+/-
	Degenerative disc disease	Subacute or chronic	Years	Dull aching	Local	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	+/-
	Disc herniation	Acute	Minutes to hours	Sharp,shooting	Legs and hips	-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-
	Discitis	Chronic	Years	Dull aching or throbbing	Local	-	+	+/-	-	+/-	-	+/-	+/-	+/-	-	-	+/-	-
	Hyperkyphosis	Chronic	Years	Dull aching	Local	+/-	-	-	-	-	-	-	+/-	+/-	-	-	-	-
	Osteoarthritis	Chronic	Years	Dull aching	Local	+	-	-	-	-	-	-	-	-	-	-	-	-
	Sacroiliac joint dysfunction	Chronic	Years	Dull aching	Hips and legs	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-
	Sacroilitis	Acute or chronic	Variable	Dull aching or throbbing	Hips and legs	+/-	+	+/-	-	-	-	+/-	+/-	+/-	-	-	+/-	-
	Scheuermann (juvenile) kyphosis	Chronic	Years	Dull aching	Shoulders and arms	+/-	-	-	-	-	-	-	-	-	-	-	-	-
	Scoliosis	Chronic	Years	Dull aching	Shoulders, arms, hips and legs	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-
	Spinal stenosis	Chronic	Years	Dull aching	Hips and legs	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	+/-
	Spondylosis	Chronic	Years	Dull aching	Shoulders, arms, hips and legs	+/-	-	-	+/-	-	-	-	+/-	+/-	-	-	+/-	+/-
	Vertebral compression fracture	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	-	-	+/-	+/-	+/-	-	+/-	+/-	-	-	+/-	-
	Vertebral osteomyelitis	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 - 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	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	Acute	Minutes to hours	Burning	Umbilicus and lower right quadrant	-	+	+/-	-	+	-	-	-	-	-	-	-	-
	Cholelithiasis	Acute or subacute	Minutes or hours	Sharp	Tip of right shoulder	-	+/-	+/-	-	+	-	+/-	-	-	-	-	-	-
	Chronic stable angina	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	Acute	Hours	Burning	Suprapubic	-	+/-	+/-	-	-	-	-	-	-	-	-	-	-
	Endocarditis	Acute or subacute	Variable	Discomfort in the chest	Jaw and arms	-	+/-	+/-	-	+/-	+/-	-	-	-	+/-	+	-	-
	Myalgia	Chronic	Years	Dull aching	Variable	+/-	+/-	+/-	+/-	-	-	-	-	-	-	-	-	-
	Nephrolithiasis	Acute	Hours	Severe, sharp	Abdomen, hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-
	Pancreatitis	Acute or chronic	Variable	Severe, sharp	Abdomen	-	+/-	+/-	-	+	+/-	+/-	-	-	-	-	-	-
	Pelvic inflammatory disease	Acute or chronic	Variable	Dullaching or throbbing	Hips, groin, legs	-	+/-	+/-	-	+/-	-	-	-	-	-	-	-	-
	Pulmonary embolism	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	Acute or chronic	Variable	Severe, sharp or dull aching	Groin, hips and legs	-	+	+/-	-	+/-	-	-	-	-	-	-	-	-
	Pneumonia	Acute or chronic	Variable	Variable	Chest, back and abdomen	-	+	+	+/-	+/-	+/-	+/-	-	-	-	-	-	-
	Pyomyositis	Acute or chronic	Days to weeks	Dull aching or throbbing	Variable	-	+	+/-	-	-	-	-	-	-	-	-	-	-
	Rheumatoid arthritis	Chronic	Years	Severe, aching	Variable	+	-	-	-	-	-	+/-	-	-	-	-	-	-
	Traumatic aortic rupture	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	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	Chronic
	Langerhans cell histiocytosis (eosinophilic granulomas)	Chronic
	Leukemia	Acute or chronic
	Lymphoma	Chronic
	Neurofibroma	Chronic
	Osteoblastoma	Chronic
	Osteoid osteoma	Chronic
	Osteosarcoma	Chronic
	Prostate cancer	Chronic
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	Chronic
	Muscle spasm	Acute
	Pyriformis syndrome	Chronic
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	Chronic
	Depression	Chronic
	Herpes zoster	Acute or chronic	Variable
	Pregnancy	Chronic
	Premenstrual syndrome	Acute
	Sickle cell anemia	Acute or chronic
	Syringomyelia	Chronic
	Trauma	Acute or chronic
	Ureteropelvic junction obstruction	Acute

References

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