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{{Backpain1}} | {{Backpain1}} | ||
the differential diagnosis of acute onset lower back pain, with bowel and bladder dysfunction, sensory and motor deficits, | |||
<small><small> | |||
{| class="wikitable" | |||
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Classification of pain in the back based on etiology | |||
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Diease | |||
! colspan="17" align="center" style="background:#4479BA; color: #FFFFFF;" |Clinical Manifestation | |||
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Diagnosis | |||
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Comments | |||
|- | |||
! colspan="11" align="center" style="background:#4479BA; color: #FFFFFF;" |Symptoms | |||
! colspan="6" align="center" style="background:#4479BA; color: #FFFFFF;" |Signs | |||
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Lab findings | |||
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Imaging | |||
|- | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Onset | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Duration | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Quality of pain | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Radiation | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Stiffness | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Fever | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Rigors and chills | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Headache | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Nausea and vomiting | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Syncopy | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Weight loss | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Motor weakness | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Sensory deficit | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Pulse Deficit | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Heart Murmur | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Bowel or bladder dysfunction | |||
! align="center" style="background:#4479BA; color: #FFFFFF;" |Horner's syndrome | |||
|- | |||
! rowspan="6" align="center" style="background:#4479BA; color: #FFFFFF;" |Neurological | |||
![[Arachnoiditis]]<ref name="pmid10665863">{{cite journal |vauthors=Ozateş M, Kemaloglu S, Gürkan F, Ozkan U, Hoşoglu S, Simşek MM |title=CT of the brain in tuberculous meningitis. A review of 289 patients |journal=Acta Radiol |volume=41 |issue=1 |pages=13–7 |date=January 2000 |pmid=10665863 |doi= |url=}}</ref> | |||
|Acute | |||
|Hours | |||
|Dull aching pain | |||
|Head, neck and back | |||
| +/- | |||
|<nowiki>+</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
| +/- | |||
|<nowiki>+/-</nowiki> | |||
| +/- | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|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]]<ref name="pmid2096606">{{cite journal |vauthors=Bach F, Larsen BH, Rohde K, Børgesen SE, Gjerris F, Bøge-Rasmussen T, Agerlin N, Rasmusson B, Stjernholm P, Sørensen PS |title=Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression |journal=Acta Neurochir (Wien) |volume=107 |issue=1-2 |pages=37–43 |date=1990 |pmid=2096606 |doi= |url=}}</ref><ref name="pmid8204366">{{cite journal |vauthors=Helweg-Larsen S, Sørensen PS |title=Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients |journal=Eur. J. Cancer |volume=30A |issue=3 |pages=396–8 |date=1994 |pmid=8204366 |doi= |url=}}</ref> | |||
|Acute | |||
|Hours | |||
|Severe, sharp local pain | |||
|Rarely to sacroiliac joint | |||
|<nowiki>-</nowiki> | |||
| - | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|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]]<ref name="pmid10201299">{{cite journal |vauthors=Nathoo N, Nadvi SS, van Dellen JR |title=Cranial extradural empyema in the era of computed tomography: a review of 82 cases |journal=Neurosurgery |volume=44 |issue=4 |pages=748–53; discussion 753–4 |date=April 1999 |pmid=10201299 |doi= |url=}}</ref><ref name="pmid14519222">{{cite journal |vauthors=Heran NS, Steinbok P, Cochrane DD |title=Conservative neurosurgical management of intracranial epidural abscesses in children |journal=Neurosurgery |volume=53 |issue=4 |pages=893–7; discussion 897–8 |date=October 2003 |pmid=14519222 |doi= |url=}}</ref> | |||
|Acute | |||
|Variable | |||
|Dull, throbbing pain | |||
|Locally | |||
|<nowiki>-</nowiki> | |||
| +/- | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|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]]<ref name="pmid8219542">{{cite journal |vauthors=Bischoff RJ, Rodriguez RP, Gupta K, Righi A, Dalton JE, Whitecloud TS |title=A comparison of computed tomography-myelography, magnetic resonance imaging, and myelography in the diagnosis of herniated nucleus pulposus and spinal stenosis |journal=J Spinal Disord |volume=6 |issue=4 |pages=289–95 |date=August 1993 |pmid=8219542 |doi= |url=}}</ref><ref name="pmid">{{cite journal |vauthors=Tarulli AW, Raynor EM |title=Lumbosacral radiculopathy |journal=Neurol Clin |volume=25 |issue=2 |pages=387–405 |date=May 2007 |pmid= |doi=10.1016/j.ncl.2007.01.008 |url=}}</ref> | |||
|Acute | |||
|Variable | |||
|Severe, shooting pain | |||
|Anterior thigh and knee | |||
| +/- | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
| - | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
| +/- | |||
|<nowiki>+/-</nowiki> | |||
| - | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
| | |||
* 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]]<ref name="pmid967084">{{cite journal |vauthors=Hay MC |title=Anatomy of the lumbar spine |journal=Med. J. Aust. |volume=1 |issue=23 |pages=874–6 |date=June 1976 |pmid=967084 |doi= |url=}}</ref><ref name="pmid9971865">{{cite journal |vauthors=Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA |title=Lack of effectiveness of bed rest for sciatica |journal=N. Engl. J. Med. |volume=340 |issue=6 |pages=418–23 |date=February 1999 |pmid=9971865 |doi=10.1056/NEJM199902113400602 |url=}}</ref><ref name="pmid9971865">{{cite journal |vauthors=Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA |title=Lack of effectiveness of bed rest for sciatica |journal=N. Engl. J. Med. |volume=340 |issue=6 |pages=418–23 |date=February 1999 |pmid=9971865 |doi=10.1056/NEJM199902113400602 |url=}}</ref> | |||
|Acute | |||
|Minutes to hours | |||
|Severe, shooting pain | |||
|Posterior thigh, buttocks and knee | |||
| +/- | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|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]]<ref name="pmid2096606">{{cite journal |vauthors=Bach F, Larsen BH, Rohde K, Børgesen SE, Gjerris F, Bøge-Rasmussen T, Agerlin N, Rasmusson B, Stjernholm P, Sørensen PS |title=Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression |journal=Acta Neurochir (Wien) |volume=107 |issue=1-2 |pages=37–43 |date=1990 |pmid=2096606 |doi= |url=}}</ref><ref name="pmid8204366">{{cite journal |vauthors=Helweg-Larsen S, Sørensen PS |title=Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients |journal=Eur. J. Cancer |volume=30A |issue=3 |pages=396–8 |date=1994 |pmid=8204366 |doi= |url=}}</ref> | |||
- Thoracic spine | |||
- Lumbar spine | |||
|Acute | |||
|Minutes to hours | |||
|Severe and localized | |||
|Locally, may radiate below lesion | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>+/-</nowiki> | |||
|<nowiki>-</nowiki> | |||
|<nowiki>-</nowiki> | |||
| | |||
+/- | |||
|<nowiki>-</nowiki> | |||
|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 | |||
|- | |||
|} | |||
</small></small> |
Latest revision as of 05:06, 5 April 2018
Template:Backpain1 the differential diagnosis of acute onset lower back pain, with bowel and bladder dysfunction, sensory and motor deficits,
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
Culture and sensitivity
Nucleic acid tests
|
Radiography
CT
MRI
|
|
Cauda equina syndrome[2][3] | Acute | Hours | Severe, sharp local pain | Rarely to sacroiliac joint | - | - | - | - | - | - | - | + | +/- | - | - | +/- | - | CBC
Electrolytes, blood urea nitrogen, and creatinine
Erythrocyte sedimentation rate
Syphilis serology
|
Radiography
MRI
Duplex
Lumbar puncture
|
Electrical studies:
EMG
SSEPs
| |
Epidural abscess[4][5] | Acute | Variable | Dull, throbbing pain | Locally | - | +/- | +/- | +/- | +/- | +/- | +/- | +/- | +/- | - | - | +/- | +/- | CBC
ESR
Culture and sensitivity
Immunohistochemical staining
|
MRI
CT
Radiography
|
| |
Radiculopathy[6][7] | Acute | Variable | Severe, shooting pain | Anterior thigh and knee | +/- | - | - | - | - | - | - | +/- | +/- | - | - | +/- | - |
|
Radiography
CT
MRI
Myelography
Discography
|
| |
Sciatica[8][9][9] | Acute | Minutes to hours | Severe, shooting pain | Posterior thigh, buttocks and knee | +/- | - | - | - | - | - | - | +/- | +/- | - | - | +/- | - | To exclude other pathologies
|
Radiography
CT
MRI
Myelography
Discography
|
| |
Spinal cord compression[2][3]
- 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
|
MRI
Radiography
Nuclear imaging
|
|
- ↑ Ozateş M, Kemaloglu S, Gürkan F, Ozkan U, Hoşoglu S, Simşek MM (January 2000). "CT of the brain in tuberculous meningitis. A review of 289 patients". Acta Radiol. 41 (1): 13–7. PMID 10665863.
- ↑ 2.0 2.1 Bach F, Larsen BH, Rohde K, Børgesen SE, Gjerris F, Bøge-Rasmussen T, Agerlin N, Rasmusson B, Stjernholm P, Sørensen PS (1990). "Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression". Acta Neurochir (Wien). 107 (1–2): 37–43. PMID 2096606.
- ↑ 3.0 3.1 Helweg-Larsen S, Sørensen PS (1994). "Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients". Eur. J. Cancer. 30A (3): 396–8. PMID 8204366.
- ↑ Nathoo N, Nadvi SS, van Dellen JR (April 1999). "Cranial extradural empyema in the era of computed tomography: a review of 82 cases". Neurosurgery. 44 (4): 748–53, discussion 753–4. PMID 10201299.
- ↑ Heran NS, Steinbok P, Cochrane DD (October 2003). "Conservative neurosurgical management of intracranial epidural abscesses in children". Neurosurgery. 53 (4): 893–7, discussion 897–8. PMID 14519222.
- ↑ Bischoff RJ, Rodriguez RP, Gupta K, Righi A, Dalton JE, Whitecloud TS (August 1993). "A comparison of computed tomography-myelography, magnetic resonance imaging, and myelography in the diagnosis of herniated nucleus pulposus and spinal stenosis". J Spinal Disord. 6 (4): 289–95. PMID 8219542.
- ↑ Tarulli AW, Raynor EM (May 2007). "Lumbosacral radiculopathy". Neurol Clin. 25 (2): 387–405. doi:10.1016/j.ncl.2007.01.008.
- ↑ Hay MC (June 1976). "Anatomy of the lumbar spine". Med. J. Aust. 1 (23): 874–6. PMID 967084.
- ↑ 9.0 9.1 Vroomen PC, de Krom MC, Wilmink JT, Kester AD, Knottnerus JA (February 1999). "Lack of effectiveness of bed rest for sciatica". N. Engl. J. Med. 340 (6): 418–23. doi:10.1056/NEJM199902113400602. PMID 9971865.