Differentials

Common

Lumbar muscular strain/sprain

History

sharp intense pain for 1 to 2 days; muscle spasm; most patients recover within 3 months[84]

Exam

benign physical examination, may reveal restricted range of motion, muscle tenderness or trigger points, diagnosis is one of exclusion

1st investigation
  • none:

    clinical diagnosis

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Other investigations
  • magnetic resonance imaging:

    no abnormality seen

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  • plain x-rays:

    no abnormalities (e.g., spondylolisthesis) or fractures are normally seen

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Herniated nucleus pulposus

History

radiating lower extremity pain in a dermatomal distribution; history of bowel or bladder dysfunction, bilateral sciatica, and saddle anaesthesia may be symptoms of severe compression of the cauda equina

Exam

positive straight-leg raise or contralateral straight leg (reproduced below 60° of hip flexion; pain that occurs above 60° is usually secondary to hamstring tightness);[65][66][67] positive femoral stretch test may suggest upper lumbar disc herniation[69]

1st investigation
  • magnetic resonance imaging (MRI):

    herniated disc

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Other investigations
  • plain x-rays:

    no abnormalities are normally found on plain x-rays

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Spinal stenosis

History

intermittent pain radiating to the thigh or legs, worse with prolonged standing, activity, or lumbar extension; pain is typically relieved by sitting, lying down, and/or lumbar flexion; patient may describe intermittent burning, numbness, heaviness, or weakness in their legs, unilateral or bilateral radicular pain, motor deficits, bowel and bladder dysfunction, and back and buttock pain with standing and ambulation

Exam

patients walk with a forward flexed gait; patients with vascular claudication have diminished pulses and typical skin changes, such as mottled discolouration, thinning and shiny skin

1st investigation
  • magnetic resonance imaging:

    spinal stenosis; hypertrophy of the facet joints and/or ligamentum flavum with corresponding decrease in spinal canal diameter dimension

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Other investigations
  • plain x-rays:

    degenerative arthritis; diffuse osteophyte formation normally seen with an accompanying degenerative spondylolisthesis or scoliosis

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Compression fracture

History

typically history of trauma, although acute event not always recalled; pain at rest and at night, previous history of fragility fractures (e.g., distal radius, hip or other vertebral compression fractures); history of osteoporosis or at risk of osteoporosis (i.e., older age, post menopausal, prolonged steroid therapy)

Exam

tenderness to palpation over the midline; increased kyphosis, normal neurological examination unless there is retropulsion of bone into the neural elements, such as in burst fractures

1st investigation
  • plain x-rays:

    wedging of the vertebral bodies, typically anteriorly; kyphotic deformity; only the anterior half of the vertebral body is involved in compression fractures

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Other investigations
  • CT lumbar spine without contrast:

    vertebral body fracture

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  • magnetic resonance imaging:

    can demonstrate bone marrow oedema to determine if the fracture is acute or chronic to help guide appropriate treatment

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  • bone scintigraphy:

    vertebral body fracture

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Degenerative disc disease or facet arthropathy

History

discogenic symptoms worsen with forward flexion, coughing/sneezing, or heavy lifting; facet mediated pain is typically worse with extension

Exam

decreased range of motion due to pain and mild tenderness on palpation; pain is reproduced with flexion in discogenic pain and extension with facet arthropathy

1st investigation
  • no initial test:

    clinical diagnosis

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Other investigations
  • magnetic resonance imaging:

    degenerative disc disease: loss of disc height, end plate collapse, and usually decreased T2 signal in the disc; annular tear; facet arthropathy: hypertrophy of the facet and possible T2 signal in the joint

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  • plain x-rays:

    degenerative arthritis and diffuse osteophyte formation

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Sacroiliitis

History

low back pain, may be lower extremity pain

Exam

tenderness on palpation at the sacroiliac joint; thigh thrust test, distraction test, Gaenslen's test, pelvic compression test, and/or FABER test may be positive. Three or more positive tests indicate that the SIJ is likely to be the pain generator.[70][71][72]

1st investigation
  • none:

    clinical diagnosis

Other investigations
  • plain x-rays:

    no other abnormalities normally seen

  • diagnostic local anaesthetic block injection to sacroiliac joint with C-arm fluoroscopic guidance:

    significant decrease in pain after sacroiliac joint injection

Uncommon

Cauda equina syndrome

History

bowel or bladder or sexual dysfunction, back pain with or without sciatica; symptoms may come on gradually; history of lumbar disc herniation, spinal stenosis, spinal injury, spinal neoplasm (primary or metastasis), infection (e.g., tuberculosis), spinal surgery

Exam

sensory changes in saddle or perianal area; sensory changes or numbness in the lower limbs; lower limb weakness, reduction or loss of reflexes in lower limbs; reduced anal tone

1st investigation
  • MRI with or without contrast:

    compression of the cauda equina

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Other investigations
  • CT lumbar spine:

    compression of the cauda equina

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  • CT myelography:

    compression of the cauda equina

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Spinal cord compression

History

localised back pain, with or without radicular pain; history of spine trauma, vertebral compression fracture, disk herniation, tumor or infection; altered sensation or hemisensory loss; weakness; constipation, urinary retention

Exam

altered sensation below a certain level or hemisensory loss; hemiplegia/hemiparesis, paraplegia/paraparesis or tetraplegia/tetraparesis; hyporeflexia (hyperreflexia can occur early if the cause is malignancy), positive Babinski sign; decreased anal tone

1st investigation
  • MRI spine:

    compression of the spinal cord

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Other investigations
  • CT spine:

    compression of the spinal cord

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Spondylolysis and/or spondylolisthesis

History

most are asymptomatic; pain in the lower back with occasional radiation to the posterior thigh and aggravated by extension

Exam

exaggerated lordosis, heart-shaped buttock, or midline 'step-off' of the spinous processes may be present; pain with single-leg hyperextension test may be present (this test has low sensitivity and specificity; a combination of findings are required for diagnosis).[73][85]​​

1st investigation
  • plain x-rays:

    linear lucency in the pars interarticularis

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Other investigations
  • magnetic resonance imaging:

    acute stress reaction in the pars interarticularis; fracture

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  • bone scintigraphy with single photon emission computed tomography of the spine:

    spondylolysis

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Vertebral discitis/osteomyelitis

History

infection should be considered for patients with a history of fever, weight loss, and non-mechanical back pain (i.e., pain that occurs even without motion, particularly at rest and at night); history of intravenous drug use, immunosuppression, or diabetes

Exam

generalised appearance of malaise; fever; localised tenderness present particularly with percussion; neurological findings absent

1st investigation
  • full blood count:

    elevated white blood cell count, particularly the neutrophil count

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  • erythrocyte sedimentation rate:

    elevated

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  • C-reactive protein:

    elevated

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  • blood cultures:

    Staphylococcus aureus and Streptococcus common

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Other investigations
  • plain x-rays:

    may demonstrate endplate/vertebral body destruction with resultant spinal deformity

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  • magnetic resonance imaging:

    reveals increased T2 signal intensity that localises to the disc space and vertebral body

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Malignancy

History

history of malignancy (breast, lung, prostate, thyroid, kidney), age >50 years, back pain at night and at rest; may have neurological deficits if tumour destruction is extensive and causes neurological compression

Exam

generalised systemic symptoms including fevers/chills, weight loss, and malaise; focal tenderness and/or neurological deficits may be present depending on tumour size and location

1st investigation
  • magnetic resonance imaging:

    either a lytic or blastic lesion with varying T2 signal intensity; lesion typically does not cross the end plate, but soft tissue extension may be present

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Other investigations
  • plain x-rays:

    may demonstrate lysis of the vertebral body or posterior elements

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  • computed tomography:

    lytic destruction of the vertebral body with possible soft tissue extension; blastic lesions possible

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  • bone scintigraphy:

    may show metastases

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Inflammatory spondyloarthropathy

History

male predominance in ankylosing spondylitis, early-morning stiffness, nocturnal back pain, fatigue, weight loss, diffuse nonspecific pain radiating bilaterally to buttocks; pain improves after physical activity or non-steroidal anti-inflammatory drugs; may have symptoms of dactylitis, enthesitis, uveitis or psoriasis; may have family history of arthritis or psoriasis; history of inflammatory bowel disease may be suggestive of enteropathic arthritis; history of recent genitourinary infection

Exam

axial spondyloarthropathy or ankylosing spondylitis: stiffness of spine with kyphosis, limited range of movement of lower spine, tenderness on palpation; extra-articular signs may be present, including enthesitis, uveitis, dactylitis, psoriasis, crohn’s disease, and ulcerative colitis

1st investigation
  • plain x-ray sacroiliac joints:

    erosion of sacroiliac joint (squaring of lumbar vertebrae) and later narrowing and fusion (bamboo spine) is suggestive of ankylosing spondylitis

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Other investigations
  • magnetic resonance imaging:

    spondylitis; fractures

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  • full blood count:

    white blood cell count may be elevated

  • C-reactive protein:

    may be normal or elevated

  • erythrocyte sedimentation rate:

    may be normal or elevated

  • human leukocyte antigen B27:

    may be positive or negative

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Connective tissue disease

History

arthralgias, polyarthritis, systemic symptoms of fever, weight loss, and fatigue

Exam

evidence of organ involvement (e.g., rash, lymphadenopathy, wheeze, signs of malabsorption, joint tenderness, joint effusion and swelling, signs of uveitis, conjunctivitis)

1st investigation
  • full blood count:

    leukopenia

  • serum antibodies:

    elevated

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  • rheumatoid factor:

    elevated in rheumatoid disease

  • erythrocyte sedimentation rate:

    elevated

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Other investigations
  • chest x-ray:

    normal; mediastinal lymphadenopathy; interstitial lung disease; pericardial effusion

  • plain x-ray of spine:

    may be evidence of rheumatoid arthritis

Scoliosis

History

back pain, postural asymmetry, adolescent patient

Exam

lateral curvature of spine in coronal plane; paraspinal and rib prominences accentuated by forward flexion; asymmetric scapular prominence; normal neurologic examination

1st investigation
  • none:

    clinical diagnosis

Other investigations
  • whole spine x-ray:

    spine curvature >10 degrees in the coronal plane

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Abdominal aortic aneurysm

History

sudden onset of intermittent or continuous abdominal pain, radiating to the back; patient may collapse; older age; history of cardiovascular disease

Exam

pulsatile abdominal mass, hypotension or hypertension, tachycardia

1st investigation
  • abdominal ultrasound:

    extent and size of aneurysm

Other investigations
  • computed tomography angiography:

    clearly defines aneurysm and involvement of visceral arteries

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Acute pancreatitis

History

sudden onset of epigastric pain; radiates to back; may be relieved by sitting forwards; associated with nausea and vomiting; history of alcohol use or gallstones

Exam

tachycardia, fever, jaundice, tenderness/guarding of abdomen

1st investigation
  • serum lipase or amylase:

    elevated (3 times the upper limit of normal)

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  • FBC:

    elevated WBC count

  • LFTs:

    elevated aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, and/or bilirubin

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  • chemistry panel:

    elevated glucose

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  • serum triglycerides:

    often elevated

Other investigations
  • ultrasound:

    may show pancreatic inflammation, peripancreatic stranding, calcifications, or fluid collections

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  • contrast-enhanced computed tomography:

    fluid collections; pseudocysts; abscess

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  • magnetic imaging/magnetic resonance cholangiopancreatography (MRI/MRCP):

    findings may include stones, tumours, diffuse or segmental enlargement of the pancreas with irregular contour and obliteration of the peripancreatic fat, necrosis, or pseudocysts

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Pyelonephritis

History

urinary symptoms of dysuria, frequency, and hesitancy; flank pain may radiate to back; fever, chills, fatigue

Exam

flank or costovertebral tenderness

1st investigation
  • urinalysis:

    pyuria, microscopic haematuria

  • urine culture:

    positive

Other investigations
  • renal ultrasound:

    gross structural abnormalities; hydronephrosis; stones; perirenal fluid collections

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  • contrast-enhanced computed tomography:

    altered renal parenchymal perfusion; altered excretion of contrast; perinephric fluid; non-renal disease

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  • MRI:

    can be normal with mild infection; with severe infection, parts of the kidney may appear oedematous and of lower attenuation; other findings may include renal calculi or gas within the collecting system; perinephric stranding can be seen

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Renal colic

History

severe, acute flank pain that may radiate to the ipsilateral groin; associated nausea and vomiting; history of volume depletion or stone-inducing medications (e.g., antacids, carbonic anhydrase inhibitors, sodium- and calcium-containing medications, vitamins C and D, indinavir)

Exam

flank or costovertebral angle tenderness; may have macroscopic haematuria

1st investigation
  • urinalysis:

    microscopic haematuria

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  • non-contrast computed tomography:

    calcification seen in renal collecting system or ureter

  • FBC:

    normal or elevated WBC count

  • serum electrolytes, urea and creatinine:

    normal or deranged

Other investigations
  • renal ultrasound:

    calcification seen within urinary tract

Peptic ulcer disease

History

epigastric, burning pain; radiates to back; usually occurs in association with meals; may be relieved by antacids; haematemesis or melaena in advanced disease

Exam

epigastric tenderness, may be melaena on rectal examination

1st investigation
  • FBC:

    microcytic anaemia; elevated WBC count

  • Helicobacter pylori test:

    may be positive

  • plain abdominal x-ray:

    may see abdominal free air on erect abdominal film if perforation present. Images of both flat (supine) and upright (erect) position are taken.

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Other investigations
  • upper gastrointestinal endoscopy:

    detects site of bleeding and ulceration

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  • upper gastrointestinal series with water-soluble contrast:

    extravasation of contrast from stomach

Spinal epidural abscess

History

focal spinal process pain, often with paravertebral spasm; pain is increased with weight-bearing and is not relieved by rest; history of diabetes mellitus, intravenous drug use, HIV infection, immune suppression, recent invasive procedures (e.g., previous spinal surgery or trauma, previous neuraxial anaesthesia associated with indwelling [intrathecal/epidural] catheter placement), dialysis, alcohol misuse; existing infections (e.g., infective endocarditis, urinary tract infection) may be a source of infection by haematogenous spread; focus of pre-existing local infection should also be ascertained, as direct extension from vertebral osteomyelitis, a psoas abscess, or a retropharyngeal abscess may be the source

Exam

fever with sweats and rigors or afebrile; signs and symptoms of neurological loss; weakness of extremities is common and may indicate impending motor weakness; sensory disturbance, abnormal reflexes (ranging from hyperreflexia to reduced or absent responses), and isolated sphincter dysfunction

1st investigation
  • FBC:

    leukocytosis

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  • C-reactive protein:

    elevated

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  • erythrocyte sedimentation rate:

    elevated

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  • gadolinium-enhanced diffusion-weighted MRI spine:

    infection in epidural space ± bone involvement

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  • blood cultures:

    identifies causative organism

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Other investigations
  • direct abscess aspiration for culture:

    identifies causative organism

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  • polymerase chain reaction (PCR) of aspirate:

    identifies causative organism

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Herpes zoster infection

History

burning, stinging or stinging pain in dermatomal distribution; pruritus, rash; risk factors (older age, immunosuppression)

Exam

rash in dermatomal distribution which does not cross the midline, initially erythematous and maculopapular, later vesicular

1st investigation
  • none:

    clinical diagnosis

Other investigations
  • polymerase chain reaction for viral DNA:

    positive for varicella zoster DNA

Retroperitoneal bleed

History

symptoms may be vague; groin, lower abdominal or back pain; history of risk factors (e.g., recent anticoagulation use, recent history of cardiac or femoral angiography, recent obstetric procedure in women of child-bearing age)

Exam

unexplained tachycardia; tenderness in lower abdomen on side of bleed; may be bruising of flank; diaphoresis if severe; profound hypotension with decreasing levels of consciousness if shock present

1st investigation
  • basic test panel (FBC, serum electrolytes, blood glucose, serum LFTs, coagulation profile, group and save):

    low Hb; INR may be raised

  • ECG:

    normal, or tachycardia

Other investigations
  • CT abdomen:

    haematoma may be visualised

  • CT angiogram:

    may demonstrate active bleeding site if bleeding is ongoing

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