Back pain and stiffness

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Abbreviations: ABG = Arterial blood gases, ANA = Antinuclear antibodies, BUN = Blood urea nitrogen, CRP = C-reactive protein, CT = Computed tomography, DRA = Dual energy radiographic absorptiometry, DRE = Digital rectal exam, ERCP = Endoscopic retrograde cholangiopancreatography, ESR = Erythrocyte sedimentation rate, HSV = Herpes simplex virus, IVP = Intravenous pyelography, KUB = Kidney, bladder, ureter, LDH = Lactate dehydrogenase, LFT = Liver function test, MRA = Magnetic resonance angiography, MRC = Magnetic resonance cholangiopancreatography, MRI = Magnetic resonance imaging, MRU = Magnetic resonance urography, NSAIDs = Non-steroidal anti-inflammatory drugs, PCR = Polymerase chain reaction, PET - FDG = Positive emission tomography - fluorodeoxyglucose, PET = Positive emission tomography, PID = Pelvic inflammatory disease, PSA = Prostatic specific antigen, PTC = Percutaneous transhepatic cholangiography, RUQ = Right upper quadrant, SPECT = Single-photon emission computed tomography, TFT = Thyroid function test, VZV = Varicella zoster virus

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^[1]	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
	Radiculopathy^[2]^[3]	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^[4]^[5]^[5]	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
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^[6]^[7]	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 Respiratory disease Renal disease Neurologic disease GI disease Metabolic bone disease Often affecting a young male
	Chronic recurrent focal osteomyelitis^[8]^[9]^[10]	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
	Degenerative disc disease^[11]^[12]	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
	Hyperkyphosis^[13]^[14]	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^[15]^[16]^[17]	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^[18]^[19]	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^[19]^[20]	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^[21]^[22]	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^[23]^[24]^[25]	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^[26]^[27]	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^[28]^[29]	Chronic^[30]	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^[31]^[32]^[33]	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	-	-	+/-	+/-	+/-	-	+/-	+/-	-	-	+/-	-	CBC Decreased hematocrit and anemia PSA To rule out prostate cancer Urine analysis To detect Bence - Jones protein Serum protein electrophoresis M spike is seen with multiple myeloma ESR May be elevated	Radiography Decreased vertebral body height CT Detects more subtle fractures and calcifications MRI Useful in those with motor weakness and sensory deficits May demonstrate hemorrhage, tumor, or infection DRA scanning Detects low bone density PET scanning To distinguish benign from malignant causes of compression	Presents as a midline back pain
	Vertebral osteomyelitis^[34]^[35]^[36]	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	+	+/-	-	+/-	-	-	+/-	+/-	-	-	+/-	-	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	Often caused by hematogenous spread of organism
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	Myalgia^[37]^[38]^[39]	Chronic	Years	Dull aching	Variable	+/-	+/-	+/-	+/-	-	-	-	-	-	-	-	-	-	*Typically no specific lab findings A full workup should be done to exclude other etiologies, such as; Rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies May indicate cause is rheumatoid arthritis CRP and ESR May be elevated CBC May indicate anemia Bone profile May be caused by a vitamin D or calcium deficiency	Typically no routine imaging done	May be associated with Hepatitis C and Lyme disease
Referred pain	Rheumatoid arthritis^[40]^[41]^[42]	Chronic	Years	Severe, aching	Variable	+	-	-	-	-	-	+/-	-	-	-	-	-	-	ESR and CRP Elevated CBC May indicate anemia Rheumatoid factor May be positive ANA May be positive Anti−cyclic citrullinated peptide (anti-CCP) and anti−mutated citrullinated vimentin (anti-MCV) Are specific to rheumatoid arthritis	Radiography Osteopenia is noted Metacarpal bone erosion Narrow joint space without osteophytes MRI Pannus formation may be noted Ultrasound Effusion of joint may be seen	Symmetric polyarthritis Morning stiffness with improvement throughout the day Deformities of the hand are common
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^[43]^[44]^[45]	Chronic	Months to years	Dull aching	Variable	+/-	+/-	+/-	-	-	-	+	-	-	-	-	-	-	Tests are used to rule out other pathologies; CBC May indicate anemia Blood cultures May be positive for various organisms ESR and CRP May be elevated LDH May be elevated Cytogenetic studies May be positive for t(11;22) translocation Immunohistochemical markers May be positive for MIC2 antigen (CD99)	Radiography Periosteal reaction "onion skin" Cortical thinning Mottling MRI Skip lesions Edema Metastasis PET - FDG To identify metastatic disease
Tumors	Multiple myeloma^[46]^[47]	Chronic	Years	Dull aching	Hips, groin and legs	+/-	+/-	+/-	-	-	-	+/-	-	-	-	-	+/-	-	Serum protein electrophoresis May demonstrate a M peak Serum free light chain assay and 24 - hour urine collection May detect Bence-Jones proteins CRP May be elevated Serum beta2-microglobulin May be elevated Albumin May demonstrate elevated albumin in urine LDH May be elevated Peripheral blood smear May demonstrate rouleaux formation > 50% Leukopenia Thrombocytopenia	Radiography, MRI and PET Osteolytic lesions may be demonstrated	Biopsy will demonstrate elevated plasma cells in the bone marrow
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^[48]^[49]^[50]^[51]	Chronic	Years	Dull aching	Shoulders, arms, hips, legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings	Typically no routine imaging done, diagnosed clinically	Back brace maybe used with gentle exercise
Muscle-related	Pyriformis syndrome^[52]^[53]	Chronic	Years	Aching	Hips and legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Typically no specific lab findings	MRI and ultrasound May be utilized in non-resolution of muscle spasm to visualize the soft tissue	Rest, bandaging and topical analgesics are often used to treat
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^[54]^[55]^[56]	Chronic	Years	Dull aching	Variable	+/-	-	-	+/-	+/-	-	-	-	-	-	-	-	-	Typically no specific lab findings, however, serology may be somewhat specific and demonstrate; Elevated IgM and/or IgG in coxsackie virus B titer Elevated IgM and/or IgG human herpes virus 6 titer Elevated IgM/IgG in C pneumoniae titer Decrease in natural killer cell percentage or activity Labs used to exclude other pathologies include; CBC May demonstrate leukopenia or leukocytosis LFT May demonstrate elevated serum transaminases, alkaline phosphatase, or lactic dehydrogenase TFT To rule out hypo/hyperthyroidism ESR Usually low Serum electrolytes Hypokalemia or hypocalcemia may be noted ANA May indicate an autoimmune disease Cortisol May indicate pathology of the adrenal gland Serum protein electrophoresis To rule out myeloma or lymphoma	CT and MRI Used to exclude other pathologies PET May demonstrate hypoperfusion of the frontoparietal and/or temporal region of the brain	Usually diagnosed by exclusion
	Depression^[57]^[58]^[58]	Chronic	Months to years	Severe to mild aching	Variable	+/-	-	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	Typically no specific lab findings Lab testing is used to diagnose organic causes and include; CBC TFT Vitamin B-12 detection Rapid plasma reagin HIV testing Electrolytes, especially calcium, phosphate, and magnesium levels BUN and creatinine LFTs Blood alcohol level Blood and urine toxicology screen ABG Dexamethasone suppression test Cosyntropin stimulation test	CT and MRI To rule out organic brain syndrome or hypopituitarism PET Allows for study of ligand-receptor binding SPECT May demonstrate regional blood flow deficits in the left anterofrontal and temporal regions	Must assess suicidal ideation
	Pregnancy^[59]^[60]^[61]^[62]^[63]	Chronic	Pregnancy term	Dull aching	Groin, hips, legs	+/-	-	-	-	-	-	-	-	-	-	-	-	-	Beta - human chorionic gonadotropin If detected usually confirms pregnancy	Typically no routine imaging is done to prevent radiation exposure, unless complication occurs an MRI may be carried out
	Sickle cell anemia^[64]^[65]^[66]	Acute or chronic	Variable	Severe, sharp	Variable	+/-	+	+/-	-	-	-	-	-	-	-	-	-	-	CBC Hemoglobin level is between 5-9 g/dl Hematocrit is decreased to 17-29% Leukocytosis with predominance of neutrophils Thrombocytopenia ESR Decreased Reticulocyte count Elevated Peripheral blood smear May demonstrate target cells, elongated cells, and sickle erythrocytes Howell - Jolly bodies in an asplenic patient Hemoglobin solubility Distinguishes between sickle cell disease and sickle cell trait Hemoglobin F Percentage of Hemoglobin F is elevated LFT, renal function test and pulmonary function test To assess organ distress or failure ABG To detect oxygen saturation Urine analysis May determine an urinary tract infection with hematuria and isosthenuria Sickling test As screening for sickle hemoglobinopathies Secretory phospholipase A2 May be increased in acute chest syndrome, a complication of sickle cell disease	Radiography Osteonecrosis Dactylitis indicated by medullary expansion, cortical thinning, trabecular resorption, and bone lucency Osteomyelitis may be present and demonstrate sequestra, cortical destruction, periosteal growth and sinus formation MRI and CT In addition to findings in radiography, may detect bone marrow hyperplasia May also be useful in ruling out renal medullary carcinoma in those presenting with hematuria Nuclear imaging Used to detect early osteonecrosis through Technetium-99m bone scanning Used to detect early osteomyelitis through detection of elevation ofwhite blood cells in Indium-11 white blood cell scanning Transcranial doppler ultrasonography Abnormally high blood flow is detected in those at increased risk of stroke Abdominal ultrasound Used to exclude other pathologies such as, cholecystitis, cholelithiasis, ectopic pregnancy, nephrolithiasis, and papillary necrosis May also be used to asses the size of the liver and spleen Echocardiography Used to diagnose pulmonary hypertension based on tricuspid regurgitant jet velocity Also used to assess abnormalities of systolic and diastolic function	Sickle cell trait confers some protection against malaria
	Syringomyelia^[67]^[68]^[69]	Chronic	Years	Dull aching	Variable	+/-	+/-	-	+/-	+/-	-	-	-	-	-	-	-	-	*Typically no specific lab findings	MRI Of choice and demonstrates a syrinx (spinal cord cyst) May also be useful in assessment of CSF flow dynamics Radiography and CT May also visualize a syrinx Gadolinium scan Useful in assessment of post-operative patients and can distinguish between a tumor, scar, and disk material Myelography Used when MRI is unfruitful, and may detect widening of spinal cord and complete subarachnoid block
	Trauma^[70]	Acute or chronic	Variable	Severe, sharp to dull aching	Variable	+/-	-	-	-	+/-	+/-	-	+/-	+/-	-	-	+/-	+/-	After establishment of first aid protocol, the following lab tests may be useful; Pregnancy test In women of child-bearing age Blood typing, screening and cross matching In case of blood transfusion Prothrombin time To assess those taking warfarin Creatine kinase To determine incidence of rhadomyolysis Blood sugar To determine hypoglycemia Cardiac enzymes To determine incidence of myocardial infarction Toxicology screen and alcohol level To determine alcoholism and drug use Serum lactate Elevated serum lactate may indicate a serious injury	To assess trauma, the following imaging may be used; Portable radiography Ultrasound CT Peritoneal tap or lavage Echocardiography

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↑ Archard LC, Bowles NE, Behan PO, Bell EJ, Doyle D (June 1988). "Postviral fatigue syndrome: persistence of enterovirus RNA in muscle and elevated creatine kinase". J R Soc Med. 81 (6): 326–9. doi:10.1177/014107688808100608. PMC 1291623. PMID 3404526.
↑ Bratton RL, Whiteside JW, Hovan MJ, Engle RL, Edwards FD (May 2008). "Diagnosis and treatment of Lyme disease". Mayo Clin. Proc. 83 (5): 566–71. doi:10.4065/83.5.566. PMID 18452688.
↑ Louati K, Berenbaum F (October 2015). "Fatigue in chronic inflammation - a link to pain pathways". Arthritis Res. Ther. 17: 254. doi:10.1186/s13075-015-0784-1. PMC 4593220. PMID 26435495.
↑ Turesson C, O'Fallon WM, Crowson CS, Gabriel SE, Matteson EL (August 2003). "Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years". Ann. Rheum. Dis. 62 (8): 722–7. PMC 1754626. PMID 12860726.
↑ Turesson C, Schaid DJ, Weyand CM, Jacobsson LT, Goronzy JJ, Petersson IF, Dechant SA, Nyähll-Wåhlin BM, Truedsson L, Sturfelt G, Matteson EL (September 2006). "Association of HLA-C3 and smoking with vasculitis in patients with rheumatoid arthritis". Arthritis Rheum. 54 (9): 2776–83. doi:10.1002/art.22057. PMID 16947780.
↑ Cotterill SJ, Ahrens S, Paulussen M, Jürgens HF, Voûte PA, Gadner H, Craft AW (September 2000). "Prognostic factors in Ewing's tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing's Sarcoma Study Group". J. Clin. Oncol. 18 (17): 3108–14. doi:10.1200/JCO.2000.18.17.3108. PMID 10963639.
↑ Nesbit ME, Gehan EA, Burgert EO, Vietti TJ, Cangir A, Tefft M, Evans R, Thomas P, Askin FB, Kissane JM (October 1990). "Multimodal therapy for the management of primary, nonmetastatic Ewing's sarcoma of bone: a long-term follow-up of the First Intergroup study". J. Clin. Oncol. 8 (10): 1664–74. doi:10.1200/JCO.1990.8.10.1664. PMID 2213103.
↑ Raney RB, Asmar L, Newton WA, Bagwell C, Breneman JC, Crist W, Gehan EA, Webber B, Wharam M, Wiener ES, Anderson JR, Maurer HM (February 1997). "Ewing's sarcoma of soft tissues in childhood: a report from the Intergroup Rhabdomyosarcoma Study, 1972 to 1991". J. Clin. Oncol. 15 (2): 574–82. doi:10.1200/JCO.1997.15.2.574. PMID 9053479.
↑ Kyle RA, Gertz MA, Witzig TE, Lust JA, Lacy MQ, Dispenzieri A, Fonseca R, Rajkumar SV, Offord JR, Larson DR, Plevak ME, Therneau TM, Greipp PR (January 2003). "Review of 1027 patients with newly diagnosed multiple myeloma". Mayo Clin. Proc. 78 (1): 21–33. doi:10.4065/78.1.21. PMID 12528874.
↑ Turesson I, Velez R, Kristinsson SY, Landgren O (March 2010). "Patterns of multiple myeloma during the past 5 decades: stable incidence rates for all age groups in the population but rapidly changing age distribution in the clinic". Mayo Clin. Proc. 85 (3): 225–30. doi:10.4065/mcp.2009.0426. PMC 2843108. PMID 20194150.
↑ Skaggs DL, Early SD, D'Ambra P, Tolo VT, Kay RM (2006). "Back pain and backpacks in school children". J Pediatr Orthop. 26 (3): 358–63. doi:10.1097/01.bpo.0000217723.14631.6e. PMID 16670549.
↑ Combs JA, Caskey PM (August 1997). "Back pain in children and adolescents: a retrospective review of 648 patients". South. Med. J. 90 (8): 789–92. PMID 9258304.
↑ Feldman DS, Hedden DM, Wright JG (2000). "The use of bone scan to investigate back pain in children and adolescents". J Pediatr Orthop. 20 (6): 790–5. PMID 11097256.
↑ Bhatia NN, Chow G, Timon SJ, Watts HG (March 2008). "Diagnostic modalities for the evaluation of pediatric back pain: a prospective study". J Pediatr Orthop. 28 (2): 230–3. doi:10.1097/BPO.0b013e3181651bc8. PMID 18388720.
↑ Cass SP (January 2015). "Piriformis syndrome: a cause of nondiscogenic sciatica". Curr Sports Med Rep. 14 (1): 41–4. doi:10.1249/JSR.0000000000000110. PMID 25574881.
↑ Natsis K, Totlis T, Konstantinidis GA, Paraskevas G, Piagkou M, Koebke J (April 2014). "Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome". Surg Radiol Anat. 36 (3): 273–80. doi:10.1007/s00276-013-1180-7. PMID 23900507.
↑ Prins JB, van der Meer JW, Bleijenberg G (January 2006). "Chronic fatigue syndrome". Lancet. 367 (9507): 346–55. doi:10.1016/S0140-6736(06)68073-2. PMID 16443043.
↑ Katon WJ, Buchwald DS, Simon GE, Russo JE, Mease PJ (1991). "Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis". J Gen Intern Med. 6 (4): 277–85. PMID 1890495.
↑ Lane TJ, Manu P, Matthews DA (October 1991). "Depression and somatization in the chronic fatigue syndrome". Am. J. Med. 91 (4): 335–44. PMID 1951377.
↑ Judd LL, Schettler PJ, Coryell W, Akiskal HS, Fiedorowicz JG (November 2013). "Overt irritability/anger in unipolar major depressive episodes: past and current characteristics and implications for long-term course". JAMA Psychiatry. 70 (11): 1171–80. doi:10.1001/jamapsychiatry.2013.1957. PMID 24026579.
↑ ^58.0 ^58.1 van Dessel NC, van der Wouden JC, Dekker J, van der Horst HE (March 2016). "Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS)". J Psychosom Res. 82: 4–10. doi:10.1016/j.jpsychores.2016.01.004. PMID 26944392.
↑ Foti T, Davids JR, Bagley A (May 2000). "A biomechanical analysis of gait during pregnancy". J Bone Joint Surg Am. 82 (5): 625–32. PMID 10819273.
↑ Bliddal M, Pottegård A, Kirkegaard H, Olsen J, Jørgensen JS, Sørensen TI, Dreyer L, Nohr EA (May 2016). "Association of Pre-Pregnancy Body Mass Index, Pregnancy-Related Weight Changes, and Parity With the Risk of Developing Degenerative Musculoskeletal Conditions". Arthritis Rheumatol. 68 (5): 1156–64. doi:10.1002/art.39565. PMID 26714126.
↑ MacEvilly M, Buggy D (March 1996). "Back pain and pregnancy: a review". Pain. 64 (3): 405–14. PMID 8783303.
↑ Sanderson PL, Fraser RD (November 1996). "The influence of pregnancy on the development of degenerative spondylolisthesis". J Bone Joint Surg Br. 78 (6): 951–4. PMID 8951013.
↑ Weinreb JC, Wolbarsht LB, Cohen JM, Brown CE, Maravilla KR (January 1989). "Prevalence of lumbosacral intervertebral disk abnormalities on MR images in pregnant and asymptomatic nonpregnant women". Radiology. 170 (1 Pt 1): 125–8. doi:10.1148/radiology.170.1.2521192. PMID 2521192.
↑ Platt OS, Thorington BD, Brambilla DJ, Milner PF, Rosse WF, Vichinsky E, Kinney TR (July 1991). "Pain in sickle cell disease. Rates and risk factors". N. Engl. J. Med. 325 (1): 11–6. doi:10.1056/NEJM199107043250103. PMID 1710777.
↑ Keeley K, Buchanan GR (August 1982). "Acute infarction of long bones in children with sickle cell anemia". J. Pediatr. 101 (2): 170–5. PMID 7097407.
↑ Resar LM, Oliva MM, Casella JF (November 1996). "Skull infarction and epidural hematomas in a patient with sickle cell anemia". J. Pediatr. Hematol. Oncol. 18 (4): 413–5. PMID 8888755.
↑ Milhorat TH (March 2000). "Classification of syringomyelia". Neurosurg Focus. 8 (3): E1. doi:10.3171/foc.2000.8.3.1. PMID 16676921.
↑ Brickell KL, Anderson NE, Charleston AJ, Hope JK, Bok AP, Barber PA (August 2006). "Ethnic differences in syringomyelia in New Zealand". J. Neurol. Neurosurg. Psychiatry. 77 (8): 989–91. doi:10.1136/jnnp.2005.081240. PMC 2077633. PMID 16549414.
↑ Larner AJ, Muqit MM, Glickman S (January 2002). "Concurrent syrinx and inflammatory central nervous system disease detected by magnetic resonance imaging: an illustrative case and review of the literature". Medicine (Baltimore). 81 (1): 41–50. PMID 11807404.
↑ Inaba K, DuBose JJ, Barmparas G, Barbarino R, Reddy S, Talving P, Lam L, Demetriades D (January 2011). "Clinical examination is insufficient to rule out thoracolumbar spine injuries". J Trauma. 70 (1): 174–9. doi:10.1097/TA.0b013e3181d3cc6e. PMID 20489662.

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[pmid7677303-37] Gumber SC, Chopra S (October 1995). "Hepatitis C: a multifaceted disease. Review of extrahepatic manifestations". Ann. Intern. Med. 123 (8): 615–20. PMID 7677303.

[pmid3404526-38] Archard LC, Bowles NE, Behan PO, Bell EJ, Doyle D (June 1988). "Postviral fatigue syndrome: persistence of enterovirus RNA in muscle and elevated creatine kinase". J R Soc Med. 81 (6): 326–9. doi:10.1177/014107688808100608. PMC 1291623. PMID 3404526.

[pmid18452688-39] Bratton RL, Whiteside JW, Hovan MJ, Engle RL, Edwards FD (May 2008). "Diagnosis and treatment of Lyme disease". Mayo Clin. Proc. 83 (5): 566–71. doi:10.4065/83.5.566. PMID 18452688.

[pmid26435495-40] Louati K, Berenbaum F (October 2015). "Fatigue in chronic inflammation - a link to pain pathways". Arthritis Res. Ther. 17: 254. doi:10.1186/s13075-015-0784-1. PMC 4593220. PMID 26435495.

[pmid12860726-41] Turesson C, O'Fallon WM, Crowson CS, Gabriel SE, Matteson EL (August 2003). "Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years". Ann. Rheum. Dis. 62 (8): 722–7. PMC 1754626. PMID 12860726.

[pmid16947780-42] Turesson C, Schaid DJ, Weyand CM, Jacobsson LT, Goronzy JJ, Petersson IF, Dechant SA, Nyähll-Wåhlin BM, Truedsson L, Sturfelt G, Matteson EL (September 2006). "Association of HLA-C3 and smoking with vasculitis in patients with rheumatoid arthritis". Arthritis Rheum. 54 (9): 2776–83. doi:10.1002/art.22057. PMID 16947780.

[pmid10963639-43] Cotterill SJ, Ahrens S, Paulussen M, Jürgens HF, Voûte PA, Gadner H, Craft AW (September 2000). "Prognostic factors in Ewing's tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing's Sarcoma Study Group". J. Clin. Oncol. 18 (17): 3108–14. doi:10.1200/JCO.2000.18.17.3108. PMID 10963639.

[pmid2213103-44] Nesbit ME, Gehan EA, Burgert EO, Vietti TJ, Cangir A, Tefft M, Evans R, Thomas P, Askin FB, Kissane JM (October 1990). "Multimodal therapy for the management of primary, nonmetastatic Ewing's sarcoma of bone: a long-term follow-up of the First Intergroup study". J. Clin. Oncol. 8 (10): 1664–74. doi:10.1200/JCO.1990.8.10.1664. PMID 2213103.

[pmid9053479-45] Raney RB, Asmar L, Newton WA, Bagwell C, Breneman JC, Crist W, Gehan EA, Webber B, Wharam M, Wiener ES, Anderson JR, Maurer HM (February 1997). "Ewing's sarcoma of soft tissues in childhood: a report from the Intergroup Rhabdomyosarcoma Study, 1972 to 1991". J. Clin. Oncol. 15 (2): 574–82. doi:10.1200/JCO.1997.15.2.574. PMID 9053479.

[pmid12528874-46] Kyle RA, Gertz MA, Witzig TE, Lust JA, Lacy MQ, Dispenzieri A, Fonseca R, Rajkumar SV, Offord JR, Larson DR, Plevak ME, Therneau TM, Greipp PR (January 2003). "Review of 1027 patients with newly diagnosed multiple myeloma". Mayo Clin. Proc. 78 (1): 21–33. doi:10.4065/78.1.21. PMID 12528874.

[pmid20194150-47] Turesson I, Velez R, Kristinsson SY, Landgren O (March 2010). "Patterns of multiple myeloma during the past 5 decades: stable incidence rates for all age groups in the population but rapidly changing age distribution in the clinic". Mayo Clin. Proc. 85 (3): 225–30. doi:10.4065/mcp.2009.0426. PMC 2843108. PMID 20194150.

[pmid16670549-48] Skaggs DL, Early SD, D'Ambra P, Tolo VT, Kay RM (2006). "Back pain and backpacks in school children". J Pediatr Orthop. 26 (3): 358–63. doi:10.1097/01.bpo.0000217723.14631.6e. PMID 16670549.

[pmid9258304-49] Combs JA, Caskey PM (August 1997). "Back pain in children and adolescents: a retrospective review of 648 patients". South. Med. J. 90 (8): 789–92. PMID 9258304.

[pmid11097256-50] Feldman DS, Hedden DM, Wright JG (2000). "The use of bone scan to investigate back pain in children and adolescents". J Pediatr Orthop. 20 (6): 790–5. PMID 11097256.

[pmid18388720-51] Bhatia NN, Chow G, Timon SJ, Watts HG (March 2008). "Diagnostic modalities for the evaluation of pediatric back pain: a prospective study". J Pediatr Orthop. 28 (2): 230–3. doi:10.1097/BPO.0b013e3181651bc8. PMID 18388720.

[pmid25574881-52] Cass SP (January 2015). "Piriformis syndrome: a cause of nondiscogenic sciatica". Curr Sports Med Rep. 14 (1): 41–4. doi:10.1249/JSR.0000000000000110. PMID 25574881.

[pmid23900507-53] Natsis K, Totlis T, Konstantinidis GA, Paraskevas G, Piagkou M, Koebke J (April 2014). "Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome". Surg Radiol Anat. 36 (3): 273–80. doi:10.1007/s00276-013-1180-7. PMID 23900507.

[pmid16443043-54] Prins JB, van der Meer JW, Bleijenberg G (January 2006). "Chronic fatigue syndrome". Lancet. 367 (9507): 346–55. doi:10.1016/S0140-6736(06)68073-2. PMID 16443043.

[pmid1890495-55] Katon WJ, Buchwald DS, Simon GE, Russo JE, Mease PJ (1991). "Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis". J Gen Intern Med. 6 (4): 277–85. PMID 1890495.

[pmid1951377-56] Lane TJ, Manu P, Matthews DA (October 1991). "Depression and somatization in the chronic fatigue syndrome". Am. J. Med. 91 (4): 335–44. PMID 1951377.

[pmid24026579-57] Judd LL, Schettler PJ, Coryell W, Akiskal HS, Fiedorowicz JG (November 2013). "Overt irritability/anger in unipolar major depressive episodes: past and current characteristics and implications for long-term course". JAMA Psychiatry. 70 (11): 1171–80. doi:10.1001/jamapsychiatry.2013.1957. PMID 24026579.

[pmid26944392-58] 58.0 ^58.1 van Dessel NC, van der Wouden JC, Dekker J, van der Horst HE (March 2016). "Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS)". J Psychosom Res. 82: 4–10. doi:10.1016/j.jpsychores.2016.01.004. PMID 26944392.

[pmid10819273-59] Foti T, Davids JR, Bagley A (May 2000). "A biomechanical analysis of gait during pregnancy". J Bone Joint Surg Am. 82 (5): 625–32. PMID 10819273.

[pmid26714126-60] Bliddal M, Pottegård A, Kirkegaard H, Olsen J, Jørgensen JS, Sørensen TI, Dreyer L, Nohr EA (May 2016). "Association of Pre-Pregnancy Body Mass Index, Pregnancy-Related Weight Changes, and Parity With the Risk of Developing Degenerative Musculoskeletal Conditions". Arthritis Rheumatol. 68 (5): 1156–64. doi:10.1002/art.39565. PMID 26714126.

[pmid8783303-61] MacEvilly M, Buggy D (March 1996). "Back pain and pregnancy: a review". Pain. 64 (3): 405–14. PMID 8783303.

[pmid8951013-62] Sanderson PL, Fraser RD (November 1996). "The influence of pregnancy on the development of degenerative spondylolisthesis". J Bone Joint Surg Br. 78 (6): 951–4. PMID 8951013.

[pmid2521192-63] Weinreb JC, Wolbarsht LB, Cohen JM, Brown CE, Maravilla KR (January 1989). "Prevalence of lumbosacral intervertebral disk abnormalities on MR images in pregnant and asymptomatic nonpregnant women". Radiology. 170 (1 Pt 1): 125–8. doi:10.1148/radiology.170.1.2521192. PMID 2521192.

[pmid1710777-64] Platt OS, Thorington BD, Brambilla DJ, Milner PF, Rosse WF, Vichinsky E, Kinney TR (July 1991). "Pain in sickle cell disease. Rates and risk factors". N. Engl. J. Med. 325 (1): 11–6. doi:10.1056/NEJM199107043250103. PMID 1710777.

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Back pain and stiffness

References

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