Differentials
Musculoskeletal lower back pain
SIGNS / SYMPTOMS
Patient may have history of obesity, stress, and psychiatric comorbidities; previous lower back pain; or prior treatment for lower back pain.
Absence of red flag symptoms (history of cancer; unexplained weight loss; immunosuppression; urinary infection; intravenous drug use; prolonged use of corticosteroids; back pain not improved with conservative management; history of significant trauma; minor fall or heavy lift in a potentially osteoporotic or older individual; prolonged use of steroids; acute onset of urinary retention or overflow incontinence; loss of anal sphincter tone or fecal incontinence; saddle anesthesia; global or progressive motor weakness in the lower limbs).[69]
Sensory, motor, and deep tendon reflexes within normal limits.
INVESTIGATIONS
Plain x-rays: normal.
MRI/CT spine: absence of disk herniation and spinal stenosis.
Acute cervical spine trauma
SIGNS / SYMPTOMS
History of neck injury or pain, or radiculopathy. Sudden onset of radicular symptoms after trauma. Head strike with or without loss of consciousness.
INVESTIGATIONS
Cervical x-ray: ligamentous instability may be seen in the form of excessive (>2 mm) anterior or posterior vertebral body translation relative to the vertebra below; avulsion or teardrop fracture may be seen at the anterior vertebral body; fractures of atlas (C1) and axis (C2) are known even in relatively lower-energy events, including hangman fracture of the axis; in more severe injury mechanisms (particularly with airbag deployment), unilateral and even bilateral facet luxation may be present with or without fracture.
Degenerative cervical spine disease
SIGNS / SYMPTOMS
Cervical spondylosis is associated with increasing age (>40 years), and there may be a family history or history of trauma, myofascial strain, or cervical surgery.
Spontaneous onset of neck pain. Cervical muscle pain and spasm. Headache or occipital pain.
INVESTIGATIONS
Cervical x-ray: presence of degenerative joint disease or degenerative disk disease, fracture, or instability.
Cervical MRI: bone destruction, spinal cord or nerve compression, intradural or epidural process.
Osteoporosis
SIGNS / SYMPTOMS
Risk factors include: older age (women >50 years; men >65 years); predominantly female sex; white ancestry; family history of hip fracture; prior fracture.
History of low-impact injury.
Exam findings: loss of height, kyphosis.
INVESTIGATIONS
DXA: score of ≤-2.5 indicates osteoporosis; T-score ≤-2.5 with fragility fracture(s) indicates severe (or established) osteoporosis.
X-ray: can reveal osteopenia.
Quantitative CT: shows reduced trabecular bone density.
Spinal osteosarcoma
SIGNS / SYMPTOMS
Rare. Worsening pain over weeks or months. Mass or swelling found on exam.
INVESTIGATIONS
X-ray: radiolucent lesion with areas of mottled radiodensity and ill-defined margins.
Metastatic bone disease
SIGNS / SYMPTOMS
History of cancer.
History of low-impact injury.
INVESTIGATIONS
CT/MRI/MRI FLAIR (fluid-attenuated inversion recovery): detection of tumor.
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