Back pain red flags

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]Hadeel Maksoud M.D.[3]

The differentials of back pain that exhibits red flags including fever, pain lasting for > 6 weeks despite conservative therapy, elevated ESR, elevated CRP, weight loss in a patient with age > 50 years, a history of immunosupression, chronic steroid use, intravenous drug use include:

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
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 elvated 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
Langerhans cell histiocytosis(eosinophilic granulomas)	Chronic	Months to years	Dull aching	Variable	−	+/−	+/−	−	−	−	−	−	−	−	−	−	−	Tests used to rule out other pathologies; CBC Reticulocyte count may be increased Positive or negative direct and indirect Coombs test Immunoglobulin levels may be elevated ESR May be elevated LFT May demonstrate elevations in total protein, albumin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma−glutamyltransferase Elevations may mean liver cirrhosis Urine analysis Decrease in urine osmolality may indicate diabetes insipidus	Radiography Single or multiple osteolytic lesions may be noted CT To identify abnormalities of the hypothalamic and/or pituitary region MRI To identify abnormalities of the hypothalamic and/or pituitary region PET − FDG More sensitive than CT or MRI to active disease
Leukemia	Acute or chronic	Weeks to years	Aching	Variable	−	+/−	+/−	−	−	−	+	−	−	−	−	−	−	CBC Mature or immature leukocytosis Coagulation study May demonstrate elevated prothrombin time, decreasing fibrinogen level, and presence of fibrin split products Peripheral blood smear May demonstrate blasts, schistocytes, 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
Neurofibroma	Chronic	Weeks to years	Aching, pressure	Variable	−	−	−	−	−	−	−	−	−	−	−	−	−	Molecular sequencing Used to detect neurofibromin gene Urine analysis Used to detect free catecholamine and their metabolites in suspected pheochromocytoma	Radiography Bowing of bones Medullary destruction MRI and CT Used to determine neurologic pathologies May demonstrate unidentified bright objects in brain scans May demonstrate optic nerve and optic chiasma involvement Bilateral acoustic neuroma is noted in neurofibromatosis type 2 PET − FDG Used to determine staging	Marfanoid habitus may be noted in neurfibromatosis type 1
Osteoblastoma	Chronic	Weeks to years	Dul aching	Variable	−	−	−	−	−	−	−	−	−	−	−	−	−	Typically no specific lab findings are noted	Radiography May demonstrate a well−circumscribed radiolucent tumor in cortex Thin shell of peripheral new bone distinct from soft tissue > 2cm in diameter No associated reactive zone CT and MRI May demonstrate size and extent of tumor relative to surrounding soft tissue Bone scan Demonstrates cortical activity within the bone Angiography Demonstrates the vascularity of the tumor	Presents in third decade of life Pain is not relieved by NSAIDs
Osteoid osteoma	Chronic	Years	Dull aching	Variable	−	−	−	−	−	−	−	−	−	−	−	−	−	Serum chemistry study High levels of prostaglandin metaboliteshave been linked with osteoid osteomas	Radiography May demonstrate sclerosis around a radiolucent nidus CT Demonstrates the margins of the nidus and calcifications present MRI Useful only in a non−calcified nidus Radionuclide scan Demonstrates increased uptake in diseased bone Arteriography Used a last resort when other imaging has been unfruitful Demonstrates 2 phases, early arterial phase, late arterial phase and venous phase	Pain is relieved by use of NSAIDs
Osteosarcoma	Chronic	Weeks to years	Severe, sharp	Variable	−	−	−	−	−	−	−	−	−	−	−	−	−	Typically no specific lab findings Elevated LDH and alkaline phosphatase may suggest pulmonary metastasis	Radiography May demonstrate an osteolytic or osteoblastic lesion Elevation of the periosteum may be noted, and is known as "Codman's triangle" Tumor spread to periosteum is known as "sunburst" sign CT Chest CT is done to rule out pulmonary involvement May also demonstrate the margins and extent of tumor MRI Useful in detection of soft tissue involvement Bone scan Increased uptake is noted in regions of metastasis Technetium−99 − methylene diphosphonate is usually used	Cardiac function should be assessed before the use of doxorubicin or daunorubicin
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 phosphtase Useful in detecting metasstasis 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
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
Cervical fracture	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

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