Back pain and weight loss

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	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
	Epidural abscess	Acute	Variable	Dull, throbbing pain	Locally	-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	-	-	+/-	+/-	CBC May show leukocytosis, left shift, thrombocytopenia, and anemia ESR Elevated Culture and sensitivity To identify causative organism Immunohistochemical staining Includes gram stain, special stains for fungi and mycobacteria, also consider brucella	MRI Of choice and demonstrates fluid collection CT Demonstrates fluid collection Radiography Demonstrates osteomyelitis or vertebral collapse	LP carries risk of spread of infection
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	Chronic recurrent focal osteomyelitis	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
	Discitis	Chronic	Years	Dull aching or throbbing	Local	-	+	+/-	-	+/-	-	+/-	+/-	+/-	-	-	+/-	-	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 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
	Sacroilitis	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
	Vertebral compression fracture	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
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	Cholelithiasis	Acute or subacute	Minutes or hours	Sharp	Tip of right shoulder	-	+/-	+/-	-	+	-	+/-	-	-	-	-	-	-	CBC Demonstrates polymorphnuclear leukocytosis LFT Elevated alanine aminotransferase and aspartate aminotransferases Elevated conjugated bilirubin Amylase and lipase Elevated	Radiography Radio-opaque stones may be present CT May indicate presence of gallstones in the distal common bile duct MRI May indicate presence of gallstones in the distal common bile duct 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
	Pancreatitis	Acute or chronic	Variable	Severe, sharp or dull aching	Abdomen	-	+/-	+/-	-	+	+/-	+/-	-	-	-	-	-	-	Amylase and lipase Elevated LFT Elevated alkaline phosphatase, total bilirubin, aspartate aminotransferase, and alanine aminotransferase CBC May demonstrate leukocytosis Serum electrolytes May indicate hypo or hypercalcemia 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 Pancreas may appear enlarged 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
	Pneumonia	Acute or chronic	Variable	Variable	Chest, back and abdomen	-	+	+	+/-	+/-	+/-	+/-	-	-	-	-	-	-	CBC Leukocytosis is often demonstrated however, white blood cell count may be normal 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
	Rheumatoid arthritis	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
	Waterhouse-Friderichsen syndrome	Acute	Minutes to hours	Sudden, severe, sharp	Back and/or flanks	-	+	+/-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	CBC May show decreased hemotocrit, leukocytosis and rarely, eosinophilia Serum electrolytes Hyponatremia Hyperkalemia Hypercalcemia Blood urea nitrogen Elevated Creatinine Elevated Plasma glucose  Hypoglycemia Serum cortisol Decreased Plasma ACTH Elevated	CT Shows adrenal enlargement or adrenal aymmetry	Short cosyntropin (Cortrosyn) stimulation test confirms the diagnosis
Classification of pain in the back based on etiology	Diease	Clinical Manifestation																	Diagnosis		Comments
		Symptoms											Signs						Lab findings	Imaging
		Onset	Duration	Quality of pain	Radiation	Stiffness	Fever	Rigors and chills	Headache	Nausea and vomiting	Syncopy	Weight loss	Motor weakness	Sensory deficit	Pulse Deficit	Heart Murmur	Bowel or bladder dysfunction	Horner's syndrome
Tumors	Ewing's sarcoma	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
	Leukemia	Acute or chronic	Weeks to years	Aching	Variable	-	+/-	+/-	-	-	-	+	-	-	-	-	-	-	CBC Mature or immature leukocytosis Coagulation study May demonstrate elevatedprothrombin time, decreasing fibrinogen level, and presence of fibrin split products Peripheral blood smear May demonstrate blasts, ppschistocyte]]s, auer rods, and mature lymphocytosis Blood chemistry profile May demonstrate tumor lysis syndrome through elevated LDH and uric acid 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	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 Useful in those with elevated alkaline phosphatase 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	Hodgkin's lymphoma is usually focal and characterized by Reed-sternberg cells Non - hodgkin's lymphoma tends to be multifocal Biopsy provides ultimate diagnosis
	Prostate cancer	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 May detect hematuria or infection	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
Miscellaneous	Depression	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 Blood alcohol level LFTs 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
	Herpes zoster	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 Used to exclude myelopathy or encephalopathy Lumbar puncture and cerebrospinal fluid analysis In cases of suspected meningitis, increased protein and pleocytosis will be noted