Differentials
Muscular pain
SIGNS / SYMPTOMS
In contrast with spinal compression fractures, focal kyphosis and height reduction are absent in muscular pain. Localised bony tenderness, which characterises the acute stage of a fracture, is also absent.
INVESTIGATIONS
Imaging tests exclude underlying fracture.
Spinal stenosis
SIGNS / SYMPTOMS
Spinal claudication (pain in the buttock, thigh, or calf) is the classic symptom of central canal stenosis. It is more common in older patients. Pain and numbness usually occurs in one or both legs on walking and is relieved by spinal flexion, so that patients report less pain when sitting or leaning on a supermarket trolley.
INVESTIGATIONS
MRI and/or CT can confirm central canal stenosis and may indicate other causes of low back pain.
Pathological fracture
SIGNS / SYMPTOMS
Differentiating pathological fractures from osteoporotic fractures can be difficult on the basis of clinical features alone.
There may be other local or systemic signs and symptoms related to the primary tumour if malignancy is present.
INVESTIGATIONS
Pathological fractures may be caused by tumour infiltration (e.g., multiple myeloma, metastatic disease) or other metabolic disease (e.g., osteomalacia).
A bone profile may be useful to exclude a metabolic cause. This includes serum calcium, albumin, parathyroid hormone, phosphate, alkaline phosphatase, magnesium, creatinine, and serum 25-hydroxyvitamin D (25OHD). Other tests such as thyroid-stimulating hormone, screening for hypercortisolism, and serum protein electrophoresis may also be considered.
MRI and CT may identify tumour pathology. Presence of a soft-tissue mass or signal change extending into the pedicle strongly suggests tumour.[64] Blastic metastases appear hypodense on T1- and T2-weighted MRI images; lytic metastases are enhanced diffusely with contrast medium.[65]
Bone scans may also show metastatic disease by revealing multiple foci of increased radionuclide uptake.
Referred pain
SIGNS / SYMPTOMS
Pain may be referred to the back from visceral disease, such as aortic aneurysm, gastrointestinal disease, renal problems, and pelvic disease (prostatitis and pelvic inflammatory disease).
INVESTIGATIONS
Physical examination, ultrasonography, and CT/MRI confirm the diagnosis. Aortic aneurysm should be suspected among older patients with coronary artery disease or multiple risk factors.
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