Back pain and bowel or bladder dysfunction

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
	Cauda equina syndrome	Acute	Hours	Severe, sharp local pain	Rarely to sacroiliac joint	-	-	-	-	-	-	-	+	+/-	-	-	+/-	-	CBC To rule out anemia Electrolytes, blood urea nitrogen, and creatinine To rule out renal failure and retroperitoneal hematoma 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 Done to rule out multiple sclerosis
	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
	Radiculopathy	Acute	Variable	Severe, shooting pain	Anterior thigh and knee	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	Typically no specific lab findings	Radiography To rule out serious underlying etiology CT Demonstrates disc herniation MRI Demonstrates disc herniation and nerve root impingement 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	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 Demonstrates disc herniation MRI Demonstrates disc herniation and nerve root impingement Myelography Used preoperatively to visualize spinal anatomy accurately Discography To localize a symptomatic disc	May have a psychological component
	Spinal cord compression - 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 CBC - May demonstrate a pancytopenia Prothrombin time and activated partial thromboplastin time - May be prolonged Metabolic profile, including calcium level and liver function - May indicate metastasis	MRI May demonstrate tumors and collapse of intervertebral spaces May distinguish between bone lesions and malignancy Radiography May demonstrates bony destruction or calcification 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
	Degenerative disc disease	Subacute or chronic	Years	Dull aching	Local	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	+/-	Serology HLA-B27 may be positive or negative IgA may be elevated ANA may be positive Rheumatoid factor may be positive CBC May indicate anemia 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 Controversial, demonstrates disc herniation	Transforaminal selective nerve root blocks are used diagnostically and therapeutically in cases presenting with radicular pain
	Disc herniation	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 Useful in lateral herniations with calcification 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	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
	Sacroiliac joint dysfunction	Chronic	Years	Dull aching	Hips and legs	+/-	-	-	-	-	-	-	+/-	+/-	-	-	+/-	-	CBC May show leukocytosis ESR May be elevated CRP May be elevated Serology ANA Rheumatoid factor HLA-B27 Metabolic panel May indicate hypothyroidism or cortisol abnormalities	Imaging is controversial, however, CT may demonstrate; Reactive spurs Sclerosis Subluxation MRI Used primarily to exclude disc herniation Nuclear imaging Used to rule out stress fractures and metastatic bone disease	Rehabilitation is often sought
	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
	Scoliosis	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	Most commonly is idiopathic
	Spinal stenosis	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	Chronic	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	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
	Vertebral osteomyelitis	Acute	Minutes to hours	Sudden, severe, sharp	Shoulders, arms, hips and legs	+/-	+	+/-	-	+/-	-	-	+/-	+/-	-	-	+/-	-	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	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
	Cystitis	Acute	Hours	Burning	Suprapubic	-	+/-	+/-	-	-	-	-	-	-	-	-	+/-	-	Urine analysis May demonstrate [[pyuria[[, hematuria, white blood cell casts and proteinuria Urine culture Detection of > 1000 colony-forming units/ml CBC May demonstrate leukocytosis and/or anemia	Typically no routine imaging done	Cystitis may be infectious, hemorrhagic, radiational, or sterile
	Pyelonephritis	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 Hydronephrosis 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
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
	Multiple myeloma	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 May demonstrate rouleaux formation > 50% Leukopenia Thrombocytopenia	Radiography, MRI and PET Osteolytic lesions may be demonstrated	Biopsy will demonstrate elevated plasma cells in the bone marrow
	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	Trauma	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 In case of blood transfusion Prothrombin time To assess those taking warfarin Creatine kinase To determine incidence of rhadomyolysis Blood sugar To determine hypoglycemia Cardiac enzymes To determine incidence of myocardial infarction 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)	Acute	Hours to days	Dull aching	Groin, hips, legs	-	+/-	+/-	+/-	+/-	-	-	-	-	-	-	+/-	-	CBC To rule out anemia Coagulation profile To rule out bleeding Electrolyte levels To rule out nephrolithiasis BUN and serum creatinine To assess kidney function Urine culture To rule out urinary tract infection	Voiding cystourethrography May demonstrate vesicoureteral reflux Ostruction usually shows hydronephrosis without reflux 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