Back pain and motor weakness

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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]

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
Neurological Arachnoiditis[1] 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[2][3] 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[4][5] 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[6][7] 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[8][9][9] 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[2][3]

- 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
Cervical fracture[10][11] 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[12][13] 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[14][15] 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[16][17] 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[18][19] 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
Sacroiliac joint dysfunction[20][21] 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[21][22] 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
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
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

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[34][35][36] 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
Miscellaneous
Trauma[37] 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






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