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 which need to be evaluated for first, which include; spinal cord or cauda equina compression, aortic dissection, aortic aneurysm, vertebral osteomyelitis, epidural abscess, and metastatic cancer. The other possible causes of back pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.

Differential Diagnosis

Life Threatening Causes

Life threatening diseases to exclude immediately include:[1][2][3][4][2][3][5][6][7][8][9][10][11][12][13][14][15][16][17]

Common Causes

Differential Diagnosis of 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
Vascular Aortic dissection[18][19][20][20][21][22] 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
  • Increased risk of occurence with Marfan syndrome
Aortic aneurysm

rupture[23][24][25] - 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:

  • Complete blood count; normochromic normocytic anemia seen in haemorrhage
  • Elevated serum electrolytes
  • Elevated liver function tests
  • Elevated amylase or lipase
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
  • Livedo reticularis may be seen and indicates thrombotic phenomenon
Chronic stable angina[26][27] 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
  • Normal, may show calcification or complications such as pleural effusion

Exercise stress testing

  • Establishes diagnosis and extent of angina

Stress Echo

  • To evaluate wall motion, normal in stable angina

Nuclear imaging

  • To assess myocardial perfusion, reduced in stable angina

CT

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

CT Angiography

  • To evaluate stenosis, <70% in stable angina

EKG

  • Normal in stable angina
  • Hallmark is relief by rest or sublingual nitroglycerin
Pulmonary embolism[28][29] Acute Minutes Sharp All over chest and back +/- - - +/- +/- +/- - - - +/- +/- - - Lab findings are not specfic and are done to rule out other diseases such as:
    • Antithrombin III deficiency
    • Protein C or protein S deficiency
    • Lupus
    • Homocystinuria
    • Malignancy
    • Connective tissue disorders
  • 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
Traumatic aortic rupture[30][31] 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:
  • Complete blood count; normochromic normocytic anemia seen in haemorrhage
  • Elevated serum electrolytes
  • Elevated liver function tests
  • Elevated amylase or lipase

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
Retroperitoneal hematoma[32][33][34] 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 haemorrhage and organ injury may be seen in:

  • Complete blood count; normochromic normocytic anemia seen in haemorrhage
  • Elevated serum electrolytes
  • Elevated liver function tests
  • Elevated amylase or lipase
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
Waterhouse-Friderichsen syndrome[35][36] Acute Minutes to hours Sudden, severe, sharp Back and/or flanks - + +/- +/- +/- +/- +/- - - - - - -
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[37] Acute Hours Dull aching pain Head, neck and back +/- + +/- +/- +/- +/- +/- +/- +/- - - +/- +/-
Cauda equina syndrome[38][39] Acute Hours Severe, sharp local pain Rarely to sacroiliac joint - - - - - - - + +/- - - +/- -
Epidural abscess[40][41] Acute Variable Dull, throbbing pain Locally - +/- +/- +/- +/- +/- +/- +/- +/- - - +/- +/-
Radiculopathy[42][43] Acute Variable Severe, shooting pain Anterior thigh and knee +/- - - - - - - +/- +/- - - +/- -
Sciatica Acute Minutes to hours
Spinal cord compression

- Thoracic spine

- Lumbar spine

Acute Minutes to hours
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 Subacute or chronic Years
Bertolotti's syndrome (Lumbosacral transitional vertebrae) Chronic Years
Chronic recurrent focal osteomyelitis Chronic Years
Cervical fracture Acute Minutes to hours
Degenerative disc disease Subacute or chronic Years
Disc herniation Acute Minutes to hours
Discitis Chronic Years
Hyperkyphosis Chronic Years
Osteoarthritis Chronic Years
Sacroiliac joint dysfunction Chronic Years
Sacroilitis Acute or chronic Variable
Scheuermann (juvenile) kyphosis Chronic Years
Scoliosis Chronic Years
Spinal stenosis Chronic
Spondylosis Chronic
Vertebral compression fracture Acute
Vertebral osteomyelitis Chronic
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
Non-spinal infections Appendicitis Acute
Endocarditis Acute or subacute
Cholelithiasis Acute or subacute Minutes or hours
Cystitis Acute
Myalgia Chronic
Nephrolithiasis Acute
Pancreatitis Acute or chronic Variable
Pyelonephritis Acute or chronic
Pelvic inflammatory disease Acute or chronic
Pneumonia Acute or chronic Variable
Pyomyositis Acute or chronic
Rheumatoid arthritis Chronic Years
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
Langerhans cell histiocytosis (eosinophilic granulomas) Chronic
Leukemia Acute or chronic
Lymphoma Chronic
Neurofibroma Chronic
Osteoblastoma Chronic
Osteoid osteoma Chronic
Osteosarcoma Chronic
Prostate cancer Chronic
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 Chronic
Muscle spasm Acute
Pyriformis syndrome Chronic
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 Chronic
Depression Chronic
Herpes zoster Acute or chronic Variable
Pregnancy Chronic
Premenstrual syndrome Acute
Sickle cell anemia Acute or chronic
Syringomyelia Chronic
Trauma Acute or chronic
Ureteropelvic junction obstruction Acute

References

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