Back pain and stiffness

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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
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

MRI

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

MRI

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
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

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
Degenerative disc disease[11][12] 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
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

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[19][20] 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[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
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
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

CRP and ESR

  • May be elevated

CBC

Bone profile

  • May be caused by a vitamin D or calcium deficiency
  • Typically no routine imaging done
Rheumatoid arthritis[40][41][42] 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
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[43][44][45] 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
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

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
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
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
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;
  • 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[57][58][58] 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
Pregnancy[59][60][61][62][63] 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[64][65][66] 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[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

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





References

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