Back pain differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Most primary care presentations for low back pain are nonspecific. Initial assessment distinguishes nonspecific low back pain from lumbar radicular syndromes, symptomatic spinal stenosis, other specific spinal disorders, and pain referred from nonspinal structures. Pain that varies with movement or loading supports a mechanical pattern but does not establish the source or exclude serious disease.[1][2]

Differentiating Mechanical Back Pain from Other Diseases

Interpreting red flags

The probability of serious spinal pathology varies by setting. A systematic review estimated prevalence at 0.8% in primary care, 2.1% in emergency care, 4.6% in secondary care, and 6.9% in tertiary care.[3] In one emergency department cohort of 1,000 patients presenting with back pain, 3.3% had serious spinal pathology and 14.6% had serious nonspinal pathology.[4]

Interpret red flags in relation to the suspected condition and care setting. A history of cancer is the most informative single flag for spinal malignancy.[5] Age over 50 or unexplained weight loss in isolation is less informative for malignancy. For vertebral fracture, older age, prolonged corticosteroid use, significant trauma, and contusion or abrasion are among the most informative findings. Some combinations of fracture features are more informative than individual findings. The absence of one red flag does not exclude serious disease; reassess if symptoms progress or the course is atypical.[6][7][8]

Selected red flags and reported diagnostic accuracy
Target condition Finding Reported estimate
Spinal malignancy History of cancer Post-test probability: 33% (95% CI, 22–46%).[6]
Spinal malignancy History of cancer plus clinical suspicion of cancer LR+ 27.9 in emergency care.[8]
Vertebral fracture Older age; prolonged corticosteroid use; severe trauma; contusion or abrasion Post-test probability: 9%, 33%, 11%, and 62%, respectively, from studies in different settings.[6]
Vertebral fracture Any three of four features in one study: female sex, age over 70, severe trauma, and prolonged corticosteroid use Post-test probability: 90% (95% CI, 34–99%).[6]
Vertebral fracture Trauma with neurologic findings LR+ 31.1 in emergency care.[8]
Spinal epidural abscess Indwelling vascular catheter; injection drug use with another site of infection LR+ 15.7 and 13.7, respectively, in emergency care.[8]
Serious spinal pathology Saddle anesthesia; acute urinary retention LR+ 11.0 and 6.4, respectively, in one emergency department cohort. The outcome was serious spinal pathology overall.[4]

LR+ = positive likelihood ratio; CI = confidence interval. These estimates describe specific studies and populations. Post-test probability depends on baseline risk, and the figures should not be combined into a scoring rule.[6][7]

Serious spinal and vascular causes

Condition Distinguishing features Initial evaluation and urgency
Cauda equina syndrome New difficulty initiating urination, altered sensation of urinary flow, urinary retention or incontinence, saddle or perineal sensory change, or new sexual dysfunction. Bilateral sciatica and progressive lower-extremity weakness may occur. Individual findings have poor sensitivity.[2][9] Emergency: Obtain immediate lumbar MRI and arrange urgent spinal surgical assessment. Lumbar MRI without contrast is an appropriate initial study. Do not wait for urinary retention or for the full symptom cluster to develop.[2][10] The NHS England GIRFT pathway calls for MRI as soon as possible and within 4 hours of the request to radiology. Post-void residual measurement is an adjunct and should not delay MRI.[11][9]
Vertebral osteomyelitis or spinal epidural abscess New or worsening focal back pain with recent bacteremia, endocarditis, injection drug use, an indwelling vascular catheter, immunosuppression, or a recent spinal procedure. Fever occurs in only 35–60% of vertebral osteomyelitis cases. The classic triad of focal pain, fever, and neurologic deficit is present in fewer than 20% of patients with spinal epidural abscess at diagnosis.[8][12][13] Urgent: Obtain ESR, CRP, blood cultures, and spinal MRI when infection is suspected. New neurologic deficits or sepsis require emergency evaluation. Elevated ESR or CRP has a reported sensitivity of 94–100% for native vertebral osteomyelitis; up to 40% of patients have a normal white blood cell count. New focal back pain after recent Staphylococcus aureus bacteremia warrants spinal imaging.[14] Contrast-enhanced MRI is preferred when spinal epidural abscess is suspected.[13]
Spinal malignancy or metastatic spinal cord compression Prior cancer is the strongest single clue. New or progressive spinal pain in a patient with cancer warrants evaluation for spinal metastases and possible epidural compression. New weakness, sensory change, or sphincter dysfunction raises concern for cord or cauda equina compression. Weight loss alone is a weak predictor.[6][15][2] Emergency if compression is suspected: Arrange whole-spine MRI as soon as possible and obtain urgent specialist assessment. NICE specifies MRI within 24 hours for suspected metastatic spinal cord compression and within 1 week for suspected spinal metastases without suspected compression. If MRI is contraindicated, NICE recommends CT. In rare cases requiring more information, myelography after CT should be performed at a neuroscience or spinal surgical centre.[16] NCCN recommends CT myelography when MRI cannot be performed (category 2A).[17] A normal CT without myelography does not reliably exclude cord compression.[18]
Vertebral fracture Significant trauma, or lesser trauma in a patient with osteoporosis, older age, or prolonged corticosteroid exposure. Age thresholds vary; age over 70 is one studied fracture flag. Focal midline tenderness, contusion, or abrasion adds to suspicion in the appropriate setting.[6][7][8] Evaluate promptly. Radiographs may be an initial test for suspected osteoporotic compression fracture. Major trauma, suspected instability, or a new neurologic deficit requires emergency evaluation; imaging depends on the trauma setting and suspected injury.[10][19]
Symptomatic abdominal aortic aneurysm or acute aortic syndrome Sudden severe back or abdominal pain, hypotension, a pulsatile abdominal mass, or a pulse deficit. Older age and smoking increase suspicion for an aneurysm.[19] The classic triad of pain, hypotension, and a pulsatile mass is often absent. For ruptured abdominal aortic aneurysm, pooled sensitivities were 53.6% for back pain, 30.9% for hypotension, and 47.1% for a pulsatile mass.[20] Emergency: In patients with suspected rupture, point-of-care ultrasound had a pooled sensitivity of 97.8% for detecting the aneurysm itself. It cannot reliably determine whether the aneurysm has ruptured.[20][21] For suspected acute aortic syndrome, the ACC/AHA recommends CT as initial imaging (Class 1, level of evidence C-LD). Transesophageal echocardiography or MRI are reasonable alternatives (Class 2a, level of evidence C-LD).[22]

Nonspecific pain and other mimics

Condition Distinguishing features Initial evaluation
Nonspecific low back pain Predominantly axial pain that may vary with posture or loading, without a focal neurologic deficit or a pattern suggesting a specific spinal or referred cause.[1][2] Clinical assessment. Routine imaging is not indicated when the evaluation supports nonspecific low back pain.[10][2]
Lumbar radicular pain or radiculopathy Leg pain in a nerve-root distribution, often extending below the knee. Straight-leg raise may reproduce radicular pain. Corresponding weakness, sensory loss, or reflex change supports radiculopathy.[1][2] Focused neurologic examination. Severe or progressive motor deficits warrant urgent assessment and MRI; symptoms suggesting cauda equina syndrome require emergency evaluation.[10][2]
Lumbar spinal stenosis versus vascular claudication Symptoms above the knees that are provoked by standing, relieved by sitting, and relieved by leaning forward (shopping-cart sign) favor neurogenic claudication (LR+ 13 in one study). Calf symptoms relieved by standing still favor vascular claudication (LR+ 20 in the same study). Diminished pulses or trophic skin changes also favor a vascular cause. Individual symptoms discriminate poorly.[23][24] Assess neurologic findings and peripheral pulses. Direct further testing to the suspected cause.[24]
Axial spondyloarthritis Back pain lasting ≥3 months with onset before age 45. Supporting features include insidious onset, prolonged morning stiffness, improvement with exercise but not rest, alternating buttock pain, and night pain that improves on getting up. Uveitis, psoriasis, inflammatory bowel disease, enthesitis, or a family history adds to suspicion.[25][2] Consider early rheumatology referral when chronic back pain began before age 45 and at least one spondyloarthritis feature is present.[26] Reported sensitivity and specificity, respectively, are 74–81% and 25–44% for inflammatory back pain; 50% and 90% for HLA-B27; 35% and 91% for elevated CRP; and 78% and 88% for sacroiliitis on MRI. These findings support clinical assessment. No formal diagnostic criteria exist; ASAS classification criteria should not substitute for clinical diagnosis.[25]
Nephrolithiasis or pyelonephritis Flank pain, colicky radiation toward the groin, hematuria, urinary symptoms, or fever favor a urinary source over isolated axial lumbar pain.[27] Urinalysis and renal imaging as indicated by the suspected cause.[27]
Gastrointestinal or pelvic disease Epigastric or right upper quadrant pain radiating to the back suggests a pancreatic or biliary source. Cyclic pain, pelvic symptoms, or possible pregnancy directs evaluation toward a pelvic source.[27] Direct examination and testing to the suspected abdominal or pelvic source; pregnancy testing and pelvic ultrasonography may be appropriate.[27]
Hip disease Anterior hip or groin pain reproduced by hip flexion or rotation favors an intra-articular hip source.[28] Examine the hip, including range of motion. Consider hip and pelvis radiographs when imaging is indicated.[28]

References

  1. ↑ 1.0 1.1 1.2 Chiarotto A, Koes BW (2022). "Nonspecific low back pain". New England Journal of Medicine. 386 (18): 1732–1740. doi:10.1056/NEJMcp2032396. PMID 35507483 Check |pmid= value (help).
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Cashin AG, Chou R, Weimer MB, McAuley JH (2026). "Low back pain: a review". JAMA. 336 (2): 144–158. doi:10.1001/jama.2026.9631. PMID 42295944 Check |pmid= value (help).
  3. ↑ Reginato LS, Machado GC, Maher CG; et al. (2026). "Prevalence of serious spinal pathologies and nonspinal conditions in low back pain: a systematic review and meta-analysis". Pain Medicine. 27 (1): 43–52. doi:10.1093/pm/pnaf078. PMID 40581763 Check |pmid= value (help).
  4. ↑ 4.0 4.1 Shaw B, Kinsella R, Henschke N, Walby A, Cowan S (2020). "Back pain "red flags": which are most predictive of serious pathology in the Emergency Department?". European Spine Journal. 29 (8): 1870–1878. doi:10.1007/s00586-020-06452-1. PMID 32495276 Check |pmid= value (help).
  5. ↑ Henschke N, Maher CG, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L (2013). "Red flags to screen for malignancy in patients with low-back pain". Cochrane Database of Systematic Reviews (2): CD008686. doi:10.1002/14651858.CD008686.pub2. PMID 23450586.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Downie A, Williams CM, Henschke N; et al. (2013). "Red flags to screen for malignancy and fracture in patients with low back pain: systematic review". BMJ. 347: f7095. doi:10.1136/bmj.f7095. PMID 24335669.
  7. ↑ 7.0 7.1 7.2 Han CS, Hancock MJ, Downie A; et al. (2023). "Red flags to screen for vertebral fracture in people presenting with low back pain". Cochrane Database of Systematic Reviews (8): CD014461. doi:10.1002/14651858.CD014461.pub2. PMID 37615643 Check |pmid= value (help).
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Department of Veterans Affairs and Department of Defense. VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. 2022.
  9. ↑ 9.0 9.1 Hennessy O, Devitt AT, Synnott K, Timlin M (2025). "Assessment and early investigation of cauda equina syndrome- a systematic review of existing international guidelines and summary of the current evidence". European Spine Journal. 34 (4): 1545–1551. doi:10.1007/s00586-025-08732-0. PMID 40000448 Check |pmid= value (help).
  10. ↑ 10.0 10.1 10.2 10.3 Expert Panel on Neurological Imaging; Hutchins TA, Peckham M; et al. (2021). "ACR Appropriateness Criteria® Low Back Pain: 2021 Update". Journal of the American College of Radiology. 18 (11S): S361–S379. doi:10.1016/j.jacr.2021.08.002. PMID 34794594 Check |pmid= value (help).
  11. ↑ NHS England, Getting It Right First Time. National Suspected Cauda Equina Syndrome Pathway. September 2025.
  12. ↑ Zimmerli W (2010). "Vertebral osteomyelitis". New England Journal of Medicine. 362 (11): 1022–1029. doi:10.1056/NEJMcp0910753. PMID 20237348.
  13. ↑ 13.0 13.1 Tande AJ, Currier BL, Osmon DR (2026). "Spinal epidural abscess". New England Journal of Medicine. 394 (16): 1621–1633. doi:10.1056/NEJMra2412728. PMID 42019020 Check |pmid= value (help).
  14. ↑ Berbari EF, Kanj SS, Kowalski TJ; et al. (2015). "2015 Infectious Diseases Society of America (IDSA) clinical practice guidelines for the diagnosis and treatment of native vertebral osteomyelitis in adults". Clinical Infectious Diseases. 61 (6): e26–e46. doi:10.1093/cid/civ482. PMID 26229122.
  15. ↑ Cole JS, Patchell RA (2008). "Metastatic epidural spinal cord compression". The Lancet Neurology. 7 (5): 459–466. doi:10.1016/S1474-4422(08)70089-9. PMID 18420159.
  16. ↑ National Institute for Health and Care Excellence. Spinal metastases and metastatic spinal cord compression. NICE guideline NG234. 2023.
  17. ↑ National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Central Nervous System Cancers. Version 4.2026. Metastatic Spine Tumors, SPINE-1.
  18. ↑ Ropper AE, Ropper AH (2017). "Acute spinal cord compression". New England Journal of Medicine. 376 (14): 1358–1369. doi:10.1056/NEJMra1516539. PMID 28379788.
  19. ↑ 19.0 19.1 Earwood JS, Doles NA, Russell RS (2025). "Acute low back pain: diagnosis and management". American Family Physician. 112 (5): 526–536. PMID 41252835 Check |pmid= value (help).
  20. ↑ 20.0 20.1 Fernando SM, Tran A, Cheng W; et al. (2022). "Accuracy of presenting symptoms, physical examination, and imaging for diagnosis of ruptured abdominal aortic aneurysm: systematic review and meta-analysis". Academic Emergency Medicine. 29 (4): 486–496. doi:10.1111/acem.14475. PMID 35220634 Check |pmid= value (help).
  21. ↑ Expert Panel on Vascular Imaging; Verma N, Steigner ML, Aghayev A; et al. (2021). "ACR Appropriateness Criteria® Suspected Retroperitoneal Bleed". Journal of the American College of Radiology. 18 (11S): S482–S487. doi:10.1016/j.jacr.2021.09.003. PMID 34794602 Check |pmid= value (help).
  22. ↑ Isselbacher EM, Preventza O, Hamilton Black J III; et al. (2022). "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease". Journal of the American College of Cardiology. 80 (24): e223–e393. doi:10.1016/j.jacc.2022.08.004. PMID 36334952 Check |pmid= value (help).
  23. ↑ Nadeau M, Rosas-Arellano MP, Gurr KR; et al. (2013). "The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation". Canadian Journal of Surgery. 56 (6): 372–377. doi:10.1503/cjs.016512. PMID 24284143.
  24. ↑ 24.0 24.1 Webb CW, Aguirre K, Seidenberg PH (2024). "Lumbar spinal stenosis: diagnosis and management". American Family Physician. 109 (4): 350–359. PMID 38648834 Check |pmid= value (help).
  25. ↑ 25.0 25.1 Bittar M, Deodhar A (2025). "Axial spondyloarthritis: a review". JAMA. 333 (5): 408–420. doi:10.1001/jama.2024.20917. PMID 39630439 Check |pmid= value (help).
  26. ↑ Poddubnyy D, van Tubergen A, Landewé R, Sieper J, van der Heijde D (2015). "Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis". Annals of the Rheumatic Diseases. 74: 1483–1487. doi:10.1136/annrheumdis-2014-207151. PMID 25990288.
  27. ↑ 27.0 27.1 27.2 27.3 Kunow A, Freyer Martins Pereira J, Chenot JF (2024). "Extravertebral low back pain: a scoping review". BMC Musculoskeletal Disorders. 25 (1): 363. doi:10.1186/s12891-024-07435-9. PMID 38714994 Check |pmid= value (help).
  28. ↑ 28.0 28.1 Chamberlain R (2021). "Hip pain in adults: evaluation and differential diagnosis". American Family Physician. 103 (2): 81–89. PMID 33448767 Check |pmid= value (help).
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