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]

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][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][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
Cervical fracture[35][36] Acute Minutes to hours Severe, sharp Shoulder and arm - - - +/- - - - +/- +/- - - - +/-
Degenerative disc disease[37][38] Subacute or chronic Years Dull aching Local +/- - - - - - - +/- +/- - - +/- +/-
Disc herniation[39][40] Acute Minutes to hours Sharp,shooting Legs and hips - - - - - - - +/- +/- - - +/- -
Discitis[41][42] Chronic Years Dull aching or throbbing Local - + +/- - +/- - +/- +/- +/- - - +/- -
Hyperkyphosis[43][44] Chronic Years Dull aching Local +/- - - - - - - +/- +/- - - - -
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
 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[48][49] Chronic Years Dull aching Hips and legs +/- - - - - - - +/- +/- - - +/- -
Sacroilitis[49][50] Acute or chronic Variable Dull aching or throbbing Hips and legs +/- + +/- - - - +/- +/- +/- - - +/- -
Scheuermann (juvenile) kyphosis[51][52] Chronic Years Dull aching Shoulders and arms +/- - - - - - - - - - - - -
Scoliosis[53][54][55] Chronic Years Dull aching Shoulders, arms, hips and legs +/- - - - - - - +/- +/- - - +/- -
Spinal stenosis[56][57] Chronic Years Dull aching Hips and legs +/- - - - - - - +/- +/- - - +/- +/-
Spondylosis[58][59] Chronic[60] Years Dull aching Shoulders, arms, hips and legs +/- - - +/- - - - +/- +/- - - +/- +/-
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
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
Tumors Ewing's sarcoma[118] Chronic Months to years Dull aching Variable +/- +/- +/- - - - + - - - - - -
Langerhans cell histiocytosis[119](eosinophilic granulomas) Chronic Months to years Dull aching Variable - +/- +/- - - - - - - - - - -
Leukemia[120] Acute or chronic Weeks to years Aching Variable - +/- +/- - - - + - - - - - -
Lymphoma[121] Chronic Months to years Aching Variable - +/- +/- - - - + - - - - - -
Neurofibroma[122] Chronic Weeks to years Aching, pressure Variable - - - - - - - - - - - - -
Osteoblastoma[123] Chronic Weeks to years Dul aching Variable - - - - - - - - - - - - -
Osteoid osteoma[124] Chronic Years Dull aching Variable - - - - - - - - - - - - -
Osteosarcoma[125] Chronic Weeks to years Severe, sharp Variable - - - - - - - - - - - - -
Multiple myeloma[126] Chronic Years Dull aching Hips, groin and legs +/- +/- +/- - - - +/- - - - - +/- -
Prostate cancer[127] 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[128] Chronic Years Dull aching Shoulders, arms, hips, legs +/- - - - - - - - - - - - -
Muscle spasm[129] Acute Days, weeks, months Aching Variable - - - - - - - - - - - - -
Pyriformis syndrome[130] 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[131] Chronic Years Dull aching Variable +/- - - +/- +/- - - - - - - - -
Depression[132] Chronic Months to years Severe to mild aching Variable +/- - - +/- +/- +/- +/- - - - - - -
Herpes zoster[133] Acute or chronic Variable Severe, sharp, electric-like Dermatomal - +/- +/- +/- +/- +/- +/- - +/- - - - -
Pregnancy[134] Chronic Pregnancy term Dull aching Groin, hips, legs +/- - - - - - - - - - - - -
Dysmenorrhea[135] Acute 3 - 7 days Burning, dull aching or severe Groin, hips, legs - - - +/- +/- - - - - - - - -
Sickle cell anemia[136] Acute or chronic Variable Severe, sharp Variable +/- + +/- - - - - - - - - - -
Syringomyelia[137] Chronic Years Dull aching Variable +/- +/- - +/- +/- - - - - - - - -
Trauma[138] Acute or chronic Variable Severe, sharp to dull aching Variable +/- - - - +/- +/- - +/- +/- - - +/- +/-
Ureteropelvic junction obstruction[139] Acute Hours to days Dull aching Groin, hips, legs - +/- +/- +/- +/- - - - - - - +/- -

References

  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.
  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.
  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.
  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.
  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.
  6. ↑ Underwood MR, Dawes P (November 1995). "Inflammatory back pain in primary care". Br. J. Rheumatol. 34 (11): 1074–7. PMID 8542211.
  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.
  8. ↑ Ropper AH, Zafonte RD (March 2015). "Sciatica". N. Engl. J. Med. 372 (13): 1240–8. doi:10.1056/NEJMra1410151. PMID 25806916.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  18. ↑ Poplin GS, McMurry TL, Forman JL, Hartka T, Park G, Shaw G, Shin J, Kim H, Crandall J (May 2015). "Nature and etiology of hollow-organ abdominal injuries in frontal crashes". Accid Anal Prev. 78: 51–7. doi:10.1016/j.aap.2015.02.015. PMID 25744173. Vancouver style error: initials (help)
  19. ↑ Kuan JK, Wright JL, Nathens AB, Rivara FP, Wessells H (February 2006). "American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries". J Trauma. 60 (2): 351–6. doi:10.1097/01.ta.0000202509.32188.72. PMID 16508495.
  20. ↑ Harris DG, Drucker CB, Brenner ML, Sarkar R, Narayan M, Crawford RS (November 2013). "Patterns and management of blunt abdominal aortic injury". Ann Vasc Surg. 27 (8): 1074–80. doi:10.1016/j.avsg.2012.09.019. PMID 23790766.
  21. ↑ Ozateş M, Kemaloglu S, Gürkan F, Ozkan U, Hoşoglu S, Simşek MM (January 2000). "CT of the brain in tuberculous meningitis. A review of 289 patients". Acta Radiol. 41 (1): 13–7. PMID 10665863.
  22. ↑ 22.0 22.1 22.2 Bach F, Larsen BH, Rohde K, Børgesen SE, Gjerris F, Bøge-Rasmussen T, Agerlin N, Rasmusson B, Stjernholm P, Sørensen PS (1990). "Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression". Acta Neurochir (Wien). 107 (1–2): 37–43. PMID 2096606.
  23. ↑ 23.0 23.1 Helweg-Larsen S, Sørensen PS (1994). "Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients". Eur. J. Cancer. 30A (3): 396–8. PMID 8204366.
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