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, including spinal cord or cauda equina compression, aortic dissection, aortic aneurysm, vertebral osteomyelitis, epidural abscess, and metastatic cancer. These should be evaluated alongside other possible causes of back pain by carefully assessing the nature of the pain, and obtaining a thorough patient history.

Differential Diagnosis of Back Pain

The following table outlines the major differential diagnoses of back pain.

To review the differential diagnosis of back pain and bowel or bladder dysfunction, click here.

To review the differential diagnosis of back pain, bowel or bladder dysfunction and horner's syndrome, click here.

To review the differential diagnosis of back pain and fever, click here.

To review the differential diagnosis of back pain, fever and stiffness, click here.

To review the differential diagnosis of back pain and heart murmur, click here.

To review the differential diagnosis of back pain and headache, click here.

To review the differential diagnosis of back pain and horner's syndrome, click here.

To review the differential diagnosis of back pain and motor weakness, click here.

To review the differential diagnosis of back pain, motor weakness and sensory deficit, click here.

To review the differential diagnosis of back pain and nausea and vomiting, click here.

To review the differential diagnosis of back pain and pulse deficit, click here.

To review the differential diagnosis of back pain and sensory deficit, click here.

To review the differential diagnosis of back pain and stiffness, click here.

To review the differential diagnosis of back pain and syncopy, click here.

To review the differential diagnosis of back pain and weight loss, click here.

To review the differential diagnosis of back pain exhibiting "red flags", click here.


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
Vascular Retroperitoneal hematoma[1][2][3] 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 hemorrhage and organ injury may be seen in:

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[4] Acute Hours Dull aching pain Head, neck and back +/- + +/- +/- +/- +/- +/- +/- +/- - - +/- +/- CSF
  • Elevated protein with normal or low glucose

Culture and sensitivity

Nucleic acid tests

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
Cauda equina syndrome[5][6] Acute Hours Severe, sharp local pain Rarely to sacroiliac joint - - - - - - - + +/- - - +/- - CBC

Electrolytes, blood urea nitrogen, and creatinine

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

Epidural abscess[7][8] Acute Variable Dull, throbbing pain Locally - +/- +/- +/- +/- +/- +/- +/- +/- - - +/- +/- CBC

ESR

  • Elevated

Culture and sensitivity

  • To identify causative organism

Immunohistochemical staining

MRI
  • Of choice and demonstrates fluid collection

CT

  • Demonstrates fluid collection

Radiography

  • LP carries risk of spread of infection
Radiculopathy[9][10] Acute Variable Severe, shooting pain Anterior thigh and knee +/- - - - - - - +/- +/- - - +/- -
  • Typically no specific lab findings

Radiography

  • To rule out serious underlying etiology

CT

MRI

Myelography

  • Used preoperatively to visualize spinal anatomy accurately

Discography

  • To localize a symptomatic disc
Sciatica[11][12][12] 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

MRI

Myelography

  • Used preoperatively to visualize spinal anatomy accurately

Discography

  • To localize a symptomatic disc
  • May have a psychological component
Spinal cord compression[5][6]

- 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 MRI
  • May demonstrate tumors and collapse of intervertebral spaces
  • May distinguish between bone lesions and malignancy

Radiography

Nuclear imaging

  • To identify neoplasms
  • Aggressive radiotherapy is often needed
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[13][14] 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

Bertolotti's syndrome[5] (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[15][16][17] Chronic Years Dull aching pain Local +/- + + - - - +/- - - - - - - CBC

ESR

  • Elevated

CRP

  • Elevated

Procalcitonin

  • Elevated

Culture and sensitivity

  • To identify causative agent
Radiography
  • Demonstrates endosteal or medullary lesion
  • Sequestration and cavity formation

MRI

CT

  • Articular and periarticular involvement

Ultrasound

  • Soft tissue abnormalities

Nuclear imaging

  • Acute presentation is often seen in children and is associated with gait abnormalities
Cervical fracture[18][19] Acute Minutes to hours Severe, sharp Shoulder and arm - - - +/- - - - +/- +/- - - - +/-
  • Typically no specific lab findings
Radiography
  • May demonstrate fracture of the vertebrae and/or preexisting pathology that may have lead to fracture

CT

  • May show pathology that was not noted on radiography

MRI

  • May show pathology that was not noted on radiography
  • If suspected should be stablized immediately
Degenerative disc disease[20][21] Subacute or chronic Years Dull aching Local +/- - - - - - - +/- +/- - - +/- +/- Serology

CBC

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

  • Transforaminal selective nerve root blocks are used diagnostically and therapeutically in cases presenting with radicular pain
Disc herniation[22][23] Acute Minutes to hours Sharp,shooting Legs and hips - - - - - - - +/- +/- - - +/- -
  • Typically no specific lab findings
MRI
  • Demonstrates the size and location of the herniated disc and surrounding soft tissue

CT myelography

Radiography

  • Demonstrates osteophytes, disc-space narrowing, and kyphosis

Discography

  • Controversial, may show endplate irregularites or annular tears
  • Often presents with parathesias and no pain
Discitis[24][25] Chronic Years Dull aching or throbbing Local - + +/- - +/- - +/- +/- +/- - - +/- - CBC

ESR

  • May be elevated

CRP

  • May be elevated

Procalcitonin

  • May be elevated

Culture and sensitivity

  • To identify causative agent
MRI
  • Narrowing of disk space and low signalling indicates edema

CT

  • Detects lesions earlier than radiography, demonstrates hypodensity of disk and destruction of endplates and calcification of annulus

Radiography

  • Disk space narrowing with destruction of endplates and calcification of annulus

Nuclear imaging

  • Focal uptake of gallium-67 and technetium-99m in area of destruction
  • Most likely due to hematogenous spread of organism
Hyperkyphosis[26][27] 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[28][29][30] 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[31][32] Chronic Years Dull aching Hips and legs +/- - - - - - - +/- +/- - - +/- - CBC

ESR

  • May be elevated

CRP

  • May be elevated

Serology

Metabolic panel

  • May indicate hypothyroidism or cortisol abnormalities
Imaging is controversial, however, CT may demonstrate;
  • Reactive spurs
  • Sclerosis
  • Subluxation

MRI

Nuclear imaging

  • Used to rule out stress fractures and metastatic bone disease
Sacroilitis[32][33] Acute or chronic Variable Dull aching or throbbing Hips and legs +/- + +/- - - - +/- +/- +/- - - +/- - CBC

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[34][35] 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[36][37][38] 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
Spinal stenosis[39][40] 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[41][42] Chronic[43] 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[44][45][46] Acute Minutes to hours Sudden, severe, sharp Shoulders, arms, hips and legs +/- - - +/- +/- +/- - +/- +/- - - +/- - CBC

PSA

Urine analysis

  • To detect Bence - Jones protein

Serum protein electrophoresis

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[47][48][49] Acute Minutes to hours Sudden, severe, sharp Shoulders, arms, hips and legs +/- + +/- - +/- - - +/- +/- - - +/- - CBC

ESR

  • Elevated

CRP

  • Elevated

Procalcitonin

  • Elevated

Culture and sensitivity

  • To identify causative agent
Radiography
  • Demonstrates endosteal or medullary lesion
  • Sequestration and cavity formation

MRI

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
Referred pain Aortic aneurysm

rupture[50][51][52] - 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: 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
Aortic dissection[53][54][55][55][56][57] 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
Appendicitis[58][59][60] Acute Minutes to hours Burning Umbilicus and lower right quadrant - + +/- - + - - - - - - - - CBC

CRP

  • May be elevated

Urine analysis

Urine 5-HIAA

Ultrasound
  • Demonstrates a non-compressible tubular structure

CT

  • Demonstrates an enlarged appendix with thickened walls and can detect abnormally located appendices

MRI

  • Useful in pregnant ladies

KUB Radiography

  • May detect an appendicolith

Barium enema

  • Demonstrates absent or incomplete filling
  • Cecal spasm may be present

Radionuclide scanning

  • Appendiceal inflammation may be present
Cholelithiasis[61][62] Acute or subacute Minutes or hours Sharp Tip of right shoulder - +/- +/- - + - +/- - - - - - - CBC

LFT

Amylase and lipase

  • Elevated
Radiography
  • Radio-opaque stones may be present

CT

MRI

Ultrasound

  • May demonstrate gallbladder wall thickening (>5 mm) and gallbladder fluid and distention
  • Gallstones may appear as echogenic foci that cast an acoustic shadow

Scintigraphy

  • May detect cystic duct obstruction

ERCP

  • Stones are seen as a filling defect and can be removed simultaneously

PTC

  • Similar to ERCP
  • Used when ERCP is not feasible
  • May be completely asymptomatic
Chronic stable angina[63][64] 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

Exercise stress testing

  • Establishes diagnosis and extent of angina

Stress Echo

Nuclear imaging

CT

  • To evaluate coronary artery calcium (cac) which may or may not be elevated

CT Angiography

EKG

Cystitis[65][66][67] Acute Hours Burning Suprapubic - +/- +/- - - - - - - - - +/- - Urine analysis

Urine culture

  • Detection of > 1000 colony-forming units/ml

CBC

  • Typically no routine imaging done
  • Cystitis may be infectious, hemorrhagic, radiational, or sterile
Endocarditis[68][69][70] Acute or subacute Variable Discomfort in the chest Jaw and arms - +/- +/- - +/- +/- - - - +/- + - - CBC

Serology

ESR

  • May be elevated

Urine analysis

Blood culture

  • To identify causative agent
  • Streptococci and HACEK organisms are culture negative
  • Organisms that grow on prosthetic valves tend to be coagulase-negative staphylococci
Echocardiography
  • Vegetations and myocardial abscesses may be present

Radiography

  • Pyogenic emboli may be seen across the lung field

Ultrasound

  • Myocardial abscesses may be seen
  • Valvular dysfunction may also be noted
Myalgia[71][72][73] 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

CRP and ESR

  • May be elevated

CBC

Bone profile

  • May be caused by a vitamin D or calcium deficiency
  • Typically no routine imaging done
Nephrolithiasis[74][75][76] Acute Hours Severe, sharp Abdomen, hips, groin, legs - +/- +/- - +/- - - - - - - - - CBC

Electrolytes

Creatinine

  • To identify potential renal injury with contrast

Uric acid

ABG

CT

IVP

  • Visualizes stones and entire urinary system

KUB radiography

  • Radio-opaque stones may be present

Ultrasound

  • For visualization of stones

Plain renal tomography

  • Can distinguish between intrarenal and extrarenal calcifications

Retrograde pyelography

  • Particularly useful for ureteric calculi visualization

Nuclear renal imaging

  • May determine a decreased renal function
Pancreatitis[77][78][79] Acute or chronic Variable Severe, sharp or dull aching Abdomen - +/- +/- - + +/- +/- - - - - - - Amylase and lipase
  • Elevated

LFT

CBC

Serum electrolytes

BUN and creatinine

  • May be elevated

Triglycerides

  • Usually elevated, however, falsely lowered during acute attack
KUB radiography
  • May demonstrate free air within abdomen, indicating a perforated viscus

Ultrasound

  • Used to visualize the pancreas and biliary tree
  • May detect microlithiasis and periampullary lesions

CT

MRC

  • May demonstrate a blockage within the biliary ducts

ERCP

  • May remove a blockage, however, can in fact cause pancreatitis
  • Usually caused by binge drinking or long standing gallstones that block the ampulla of Vater
  • Vomiting is a common manifestation
Pelvic inflammatory disease[80][81][82] Acute or chronic Variable Dullaching or throbbing Hips, groin, legs - +/- +/- - +/- - - - - - - - - CBC

Pregnancy test

STD panel

Urine analysis

Transvaginal ultrasound
  • May demonstrate anechoic structures in adnexa indicating hydrosalpinx and/or pyosalpinx

Laparoscopy

MRI and CT

  • May indicate hydro and/ or pyosalpinx
  • Inflammation may spread to perihepatic structures (Fitz-Hugh−Curtis syndrome)
Pulmonary embolism[83][84][85] Acute Minutes Severe, sharp Chest and back - - - +/- +/- +/- - - - +/- +/- - - Lab findings are not specfic and are done to rule out other diseases such as:
  • 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[86] 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

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[87][88][89] Acute or chronic Variable Variable Chest, back and abdomen - + + +/- +/- +/- +/- - - - - - - CBC

Blood culture

  • To identify causative organism or rule out other organisms such as MRSA
Radiography
  • Plain x-ray shows multiple patches in the lung fields

CT

  • Used to distinguish pneumonia from non-pneumonias
  • Hospital-acquired pneumonia is common
Pyomyositis[90][91][92][93] Acute or chronic Days to weeks Dull aching or throbbing Variable - + +/- - - - - - - - - - - CBC

ESR

  • Elevated

Serum creatine kinase and aldolase

  • Normal

Blood culture

  • Typically negative

Culture and sensitivity

  • May include a positive gram stain
MRI
  • Can differentiate between osteomyelitis and pyomyositis by demonstrating early muscle inflammation or abscess formation

CT

  • May demonstrate pphypertrophy]] of muscles and/or effacement of fatty plane
  • An enhancement in contrast may indicate abscess formation

Ultrasound

  • Useful in determining specific muscle involvement

Gallium scan

  • Useful in detecting early muscle pathology
  • Infectious myositis was once considered a tropical disease, however with the emergence of HIV is now prevalent in western societies too
Rheumatoid arthritis[94][95][96] Chronic Years Severe, aching Variable + - - - - - +/- - - - - - - ESR and CRP
  • Elevated

CBC

Rheumatoid factor

  • May be positive

ANA

  • May be positive

Anti−cyclic citrullinated peptide (anti-CCP) and anti−mutated citrullinated vimentin (anti-MCV)

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
Traumatic aortic rupture[97][98] Acute Minutes to hours Sharp and knife-like, also tearing or ripping Back and/ or flanks - - - - - +/- - - - +/- +/- - - Typically no specific lab findings, however, evidence of hemorrhage and organ injury may be seen in: 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[99][100] Acute Minutes to hours Sudden, severe, sharp Back and/or flanks - + +/- +/- +/- +/- +/- - - - - - - CBC

Serum electrolytes

Blood urea nitrogen

  • Elevated

Creatinine

  • Elevated

Plasma glucose 

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[101][102][103] Chronic Months to years Dull aching Variable +/- +/- +/- - - - + - - - - - -

Tests are used to rule out other pathologies; CBC

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
Langerhans cell histiocytosis[104][105][106][106](eosinophilic granulomas) Chronic Months to years Dull aching Variable - +/- +/- - - - - - - - - - - Tests used to rule out other pathologies;

CBC

ESR

  • May be elevated

LFT

Urine analysis

Radiography
  • Single or multiple osteolytic lesions may be noted

CT

  • To identify abnormalities of the hypothalamic and/or pituitary region

MRI

  • To identify abnormalities of the hypothalamic and/or pituitary region

PET - FDG

  • More sensitive than CT or MRI to active disease
Leukemia[107][108][109][110] Acute or chronic Weeks to years Aching Variable - +/- +/- - - - + - - - - - - CBC

Coagulation study

Peripheral blood smear

  • May demonstrate blasts, ppschistocyte]]s, auer rods, and mature lymphocytosis

Blood chemistry profile

Blood culture

  • To rule out infection
  • Typically no routine imaging studies, cytogenetic and flow cytometries aid diagnosis
  • Acute and chronic, lymphocytic and myeloid diagnoses are based on the presence and type of blast or mature cell
Lymphoma[111][112][113][114] Chronic Months to years Aching Variable - +/- +/- - - - + - - - - - - Typically no specific lab findings, however, the following routine tests are performed;
  • CBC
  • Serum chemistry studies, including LDH
  • Serum beta2-microglobulin level
  • HIV serology
Radiography
  • May demonstrate hilar or mediastinal adenopathy
  • Pleural or pericardial effusion
  • Parenchymal involvement
  • Bulky mediastinal mass

CT

  • May demonstrate enlarged lymph nodes
  • Hepatosplenomegaly
  • Filling defects in visceral organs

Bone scan

Gallium scan

  • May show increased uptake

MRI

  • Signal intensity changes are noted in those with bone marrow or muscular involvement

PET - FDG

  • To distinguish between viable, active tumors and necrosis
  • To detect early recurrence

Ultrasound

  • Useful if primary lesion is in testis
Multiple myeloma[115][116] 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

Radiography, MRI and PET
  • Osteolytic lesions may be demonstrated
  • Biopsy will demonstrate elevated plasma cells in the bone marrow
Neurofibroma[117] Chronic[118][119] Weeks to years Aching, pressure Variable - - - - - - - - - - - - - Molecular sequencing
  • Used to detect neurofibromin gene

Urine analysis

Radiography
  • Bowing of bones
  • Medullary destruction

MRI and CT

PET - FDG

  • Used to determine staging
Osteoblastoma[120][121][122] Chronic Weeks to years Dul aching Variable - - - - - - - - - - - - -
  • Typically no specific lab findings are noted
Radiography
  • May demonstrate a well-circumscribed radiolucent tumor in cortex
  • Thin shell of peripheral new bone distinct from soft tissue
  • > 2cm in diameter
  • No associated reactive zone

CT and MRI

  • May demonstrate size and extent of tumor relative to surrounding soft tissue

Bone scan

  • Demonstrates cortical activity within the bone

Angiography

  • Demonstrates the vascularity of the tumor
  • Presents in third decade of life
  • Pain is not relieved by NSAIDs
Osteoid osteoma[123][124][120] Chronic Years Dull aching Variable - - - - - - - - - - - - - Serum chemistry study Radiography
  • May demonstrate sclerosis around a radiolucent nidus

CT

  • Demonstrates the margins of the nidus and calcifications present

MRI

  • Useful only in a non-calcified nidus

Radionuclide scan

  • Demonstrates increased uptake in diseased bone

Arteriography

  • Used a last resort when other imaging has been unfruitful
  • Demonstrates 2 phases, early arterial phase, late arterial phase and venous phase
  • Pain is relieved by use of NSAIDs
Osteosarcoma[125][126][127][128] Chronic Weeks to years Severe, sharp Variable - - - - - - - - - - - - -

Radiography

  • May demonstrate an osteolytic or osteoblastic lesion
  • Elevation of the periosteum may be noted, and is known as "Codman's triangle"
  • Tumor spread to periosteum is known as "sunburst" sign

CT

  • Chest CT is done to rule out pulmonary involvement
  • May also demonstrate the margins and extent of tumor

MRI

  • Useful in detection of soft tissue involvement

Bone scan

  • Increased uptake is noted in regions of metastasis
  • Technetium-99 - methylene diphosphonate is usually used
  • Cardiac function should be assessed before the use of doxorubicin or daunorubicin
Prostate cancer[129][130] Chronic Months to years Severe, sharp Lower abdomen, hips, groin and legs - +/- +/- - - - +/- - - - - +/- - PSA
  • Detection is helpful in diagnosis, usually > 10 ng/ml

Acid and alkaline phosphatase

  • Useful in detecting metastasis

Serurm creatinine and LFT

  • Useful in detecting metasstasis

Urine analysis

Ultrasound
  • Transrectal biopsy transrectal ultrasound may demonstrate hypoechoicity

MRI

  • May be used to guide biopsy
  • PSA and DRE are gold standard for screening
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[131][132][133][134] 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 spasm[135][136] Acute Days, weeks, months Aching Variable - - - - - - - - - - - - -
  • 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
Pyriformis syndrome[137][138] 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
Miscellaneous Chronic fatigue syndrome[139][140][141] Chronic Years Dull aching Variable +/- - - +/- +/- - - - - - - - -
  • Typically no specific lab findings, however, serology may be somewhat specific and demonstrate;
  • Labs used to exclude other pathologies include;

CBC

LFT

TFT

ESR

  • Usually low

Serum electrolytes

ANA

  • May indicate an autoimmune disease

Cortisol

Serum protein electrophoresis

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[142][143][143] Chronic Months to years Severe to mild aching Variable +/- - - +/- +/- +/- +/- - - - - - - CT and MRI

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
Dysmenorrhea[144][145] Acute 3 - 7 days Burning, dull aching or severe Groin, hips, legs - - - +/- +/- - - - - - - - - Ultrasound

Hysterosalpingography

IVP

  • May demonstrate a uterine malformation

CT

MRI

Herpes zoster[146][147][148] Acute or chronic Variable Severe, stabbing, electric-like Dermatomal - +/- +/- +/- +/- +/- +/- - +/- - - - - Tzanck smear
  • May demonstrate multinucleated giant cells

Direct fluorescent antibody test and/or PCR

  • Allows for differentiation between HSV and VZV
  • Typically no routine imaging

MRI

Lumbar puncture and cerebrospinal fluid analysis

Pregnancy[149][150][151][152][153] Chronic Pregnancy term Dull aching Groin, hips, legs +/- - - - - - - - - - - - - Beta - human chorionic gonadotropin
  • Typically no routine imaging is done to prevent radiation exposure, unless complication occurs an MRI may be carried out
Sickle cell anemia[154][155][156] Acute or chronic Variable Severe, sharp Variable +/- + +/- - - - - - - - - - - CBC

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

Hemoglobin F

LFT, renal function test and pulmonary function test

  • To assess organ distress or failure

ABG

Urine analysis

Sickling test

  • As screening for sickle hemoglobinopathies

Secretory phospholipase A2

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

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[157][158][159] 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[160] 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

Prothrombin time

Creatine kinase

Blood sugar

Cardiac enzymes

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
Ureteropelvic junction obstruction (UPJ)[161][162][163] Acute Hours to days Dull aching Groin, hips, legs - +/- +/- +/- +/- - - - - - - +/- - CBC

Coagulation profile

  • To rule out bleeding

Electrolyte levels

BUN and serum creatinine

  • To assess kidney function

Urine culture

Voiding cystourethrography

Renal ultrasonography

  • May determine kidney malformation and scarring
  • Dilation of collecting system
  • Annular stricturing

IVP

  • May demonstrate a hydronephrotic kidney
  • Used to map out entire urinary system

CT and MRU

  • Provides detail about the urinary system such as;
    • Renal vasculature
    • Renal pelvis anatomy
    • Location of crossing vessels
    • Renal cortical scarring
    • Ureteral fetal folds in the proximal ureter

Doppler

  • Used to detect cross vessels associated with obstruction

MRA

  • May demonstrate aberrant renal vessels
  • Congenital abrnormalities in both children and adults are usually the cause of UPJ obstruction

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