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Back pain

Medicine > Neurosciences

Differential Diagnosis Schema 🧠

Mechanical Causes

  • Lumbar Strain: Common cause, usually due to muscle or ligament injury, often after physical exertion.
  • Degenerative Disc Disease: Age-related changes in the intervertebral discs, can cause chronic back pain.
  • Spondylolisthesis: Vertebra slips out of place, causing pain, particularly when standing or walking.
  • Facet Joint Osteoarthritis: Degeneration of facet joints causing pain typically worsened by extension movements.
  • Vertebral Compression Fracture: Often due to osteoporosis, sudden onset of pain, especially in older adults.

Inflammatory Causes

  • Ankylosing Spondylitis: Chronic inflammatory condition, back pain improves with exercise, associated with morning stiffness.
  • Psoriatic Arthritis: Inflammatory arthritis associated with psoriasis, often involves the spine.
  • Reactive Arthritis: Occurs after infection, may involve the spine, associated with urethritis, conjunctivitis.
  • Sacroiliitis: Inflammation of one or both sacroiliac joints, associated with inflammatory bowel disease or ankylosing spondylitis.

Malignant Causes

  • Metastatic Cancer: Common primary sites include breast, lung, prostate, can present with unremitting back pain, night pain.
  • Multiple Myeloma: Malignancy of plasma cells, may cause bone pain, especially in the spine, associated with systemic symptoms.
  • Primary Bone Tumors: Less common, but can include osteosarcoma, chondrosarcoma, often progressive pain unresponsive to rest.

Infectious Causes

  • Vertebral Osteomyelitis: Infection of the vertebral body, associated with fever, localized pain, often in immunocompromised patients.
  • Discitis: Infection of the intervertebral disc, often presents with severe, localized pain and fever.
  • Epidural Abscess: Collection of pus in the epidural space, associated with severe back pain, fever, neurological deficits.

Visceral Causes

  • Abdominal Aortic Aneurysm: Severe, sudden onset of back pain, may be associated with a pulsatile abdominal mass.
  • Pancreatitis: Severe epigastric pain radiating to the back, often related to alcohol or gallstones.
  • Renal Colic: Severe, cramping flank pain radiating to the groin, associated with hematuria.
  • Peptic Ulcer Disease: Epigastric pain that may radiate to the back, associated with meals and relieved by antacids.

Key Points in History 🥼

Onset and Duration

  • Acute: Suggests strain, disc herniation, or fracture.
  • Chronic: More consistent with degenerative or inflammatory conditions.
  • Insidious onset: May suggest malignancy or infection.

Location of Pain

  • Central: Common in discogenic or spinal stenosis pain.
  • Unilateral: May suggest radiculopathy due to nerve root compression.
  • Radiation: Pain radiating to legs suggests sciatica or nerve root involvement.

Alleviating and Exacerbating Factors

  • Relief with rest: Common in mechanical causes like lumbar strain.
  • Relief with activity: Suggests inflammatory conditions such as ankylosing spondylitis.
  • Worsening with activity: Suggests conditions like vertebral compression fracture or spondylolisthesis.
  • Worsening with meals: May suggest peptic ulcer disease if pain radiates to the back.

Associated Symptoms

  • Fever: May indicate an infectious cause such as vertebral osteomyelitis or epidural abscess.
  • Weight loss: Can suggest malignancy.
  • Neurological symptoms: Weakness, numbness, or bowel/bladder dysfunction suggest nerve compression or cauda equina syndrome.
  • Morning stiffness: Common in inflammatory conditions like ankylosing spondylitis.

Background

  • Past Medical History: Previous episodes of back pain, history of cancer, autoimmune diseases.
  • Drug History: Steroid use (risk of osteoporosis), immunosuppressants (risk of infection).
  • Family History: History of ankylosing spondylitis or other autoimmune conditions.
  • Social History: Occupation (manual labor), smoking (risk of cancer, osteoporosis), alcohol use (risk of pancreatitis).

Possible Investigations 🌡️

Laboratory Tests

  • Full Blood Count: To check for infection (raised WBC) or anemia (may suggest malignancy).
  • ESR/CRP: Raised levels suggest inflammation or infection.
  • Bone Profile: Calcium, phosphate, and alkaline phosphatase levels may indicate bone pathology.
  • Serum Electrophoresis: To check for paraproteins in multiple myeloma.

Imaging

  • X-ray: Useful for detecting fractures, spondylolisthesis, and significant degenerative changes.
  • MRI: Gold standard for assessing soft tissues, including discs, spinal cord, and identifying infections or tumors.
  • CT Scan: Best for detailed bone assessment, useful in cases where MRI is contraindicated.
  • Bone Scan: Useful for detecting metastatic disease, fractures not visible on X-ray, and osteomyelitis.

Special Tests

  • Nerve Conduction Studies: May be used to assess radiculopathy or other nerve compression syndromes.
  • DEXA Scan: To assess bone mineral density in suspected osteoporosis or fragility fractures.
  • Biopsy: If malignancy or infection is suspected, a biopsy may be required to confirm the diagnosis.

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Neurosciences