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:[1][2][3][4][2][3][5][6][7][8][9][10][11][12][13][14][15][16][17]
- 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 | 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 | Aortic dissection | Severe and sudden (acute) and rarely, chronic | Minutes to hours | Sharp and knife-like, also tearing or ripping | - | - | - | - | - | +/- | - | - | - | + | +/- | - | - |
|
||
| Aortic aneurysm
rupture - Abdominal aortic aneurysm |
Acute | Minutes to hours | ||||||||||||||||||
| Chronic stable angina | Chronic | Variable | ||||||||||||||||||
| Pulmonary embolism | Acute | Minutes to hours | ||||||||||||||||||
| Traumatic aortic rupture | Acute | Minutes to hours | ||||||||||||||||||
| Retroperitoneal hematoma | Acute or subacute | Minutes to hours | ||||||||||||||||||
| Waterhouse-Friderichsen syndrome | Acute | Minutes to hours | ||||||||||||||||||
| Neurological | Arachnoiditis | Acute | Hours | |||||||||||||||||
| Cauda equina syndrome | Acute | Hours | ||||||||||||||||||
| Epidural abscess | Acute | Variable | ||||||||||||||||||
| Radiculopathy | Acute | Variable | ||||||||||||||||||
| Sciatica | Acute | Minutes to hours | ||||||||||||||||||
| Spinal cord compression
- Thoracic spine - Lumbar spine |
Acute | Minutes to hours | ||||||||||||||||||
| Bone | Ankylosing spondylitis | Subacute or chronic | Years | |||||||||||||||||
| Bertolotti's syndrome (Lumbosacral transitional vertebrae) | Chronic | Years | ||||||||||||||||||
| Chronic recurrent focal osteomyelitis | Chronic | Years | ||||||||||||||||||
| Cervical fracture | Acute | Minutes to hours | ||||||||||||||||||
| Degenerative disc disease | Subacute or chronic | Years | ||||||||||||||||||
| Disc herniation | Acute | Minutes to hours | ||||||||||||||||||
| Discitis | Chronic | Years | ||||||||||||||||||
| Hyperkyphosis | Chronic | Years | ||||||||||||||||||
| Osteoarthritis | Chronic | Years | ||||||||||||||||||
| Sacroiliac joint dysfunction | Chronic | Years | ||||||||||||||||||
| Sacroilitis | Acute or chronic | Variable | ||||||||||||||||||
| Scheuermann (juvenile) kyphosis | Chronic | Years | ||||||||||||||||||
| Scoliosis | Chronic | Years | ||||||||||||||||||
| Spinal stenosis | Chronic | |||||||||||||||||||
| Spondylosis | Chronic | |||||||||||||||||||
| Vertebral compression fracture | Acute | |||||||||||||||||||
| Vertebral osteomyelitis | Chronic | |||||||||||||||||||
| Non-spinal infections | Appendicitis | Acute | ||||||||||||||||||
| Endocarditis | Acute or subacute | |||||||||||||||||||
| Cholelithiasis | Acute or subacute | Minutes or hours | ||||||||||||||||||
| Cystitis | Acute | |||||||||||||||||||
| Myalgia | Chronic | |||||||||||||||||||
| Nephrolithiasis | Acute | |||||||||||||||||||
| Pancreatitis | Acute or chronic | Variable | ||||||||||||||||||
| Pyelonephritis | Acute or chronic | |||||||||||||||||||
| Pelvic inflammatory disease | Acute or chronic | |||||||||||||||||||
| Pneumonia | Acute or chronic | Variable | ||||||||||||||||||
| Pyomyositis | Acute or chronic | |||||||||||||||||||
| Rheumatoid arthritis | Chronic | Years | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Muscle-related | Abnormal posturing | Chronic | ||||||||||||||||||
| Muscle spasm | Acute | |||||||||||||||||||
| Pyriformis syndrome | Chronic | |||||||||||||||||||
| 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
- ↑ 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.