Low Back Pain Differential Diagnosis PDF

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Summary

Differential diagnosis summary that will come in handy for clinical exam ISCE in fourth year....

Description

Low Back Pain

Degenerative Lumbar spondylosis Disc prolapse Facet joint arthritis Lumbar stenosis Spondylolisthesis

Mechanical Minor sprain or strained

Bone disorders

Malignancy

Osteoporosis Paget’s disease of bone

Trauma

Psoriatic arthritis

Spinal fracture

Reactive arthritis

Infection Osteomyelitis – TB, S. aureus

Neurological

Extrinsic/Outside of spinal column Dissecting/ruptured AAA Nephrolithiasis Pyelonephritis PID, ectopic pregnancy

Primary malignancy Multiple myeloma

Cauda equina syndrome

Inflammatory arthropathy Ankylosing spondylitis

Osteosarcoma

Metastases Breast, prostate, lung, kidney, thyroid

LOWER BACK PAIN DIFFERENTIAL DIAGNOSIS Condition

Symptoms

Signs

Investigations

Management

• Position dependent (may feel better when lying down or sitting) • Worse when moving • Develop suddenly or gradually • Precipitated by poor posture, lifting

• Tenderness over lower back • No other abnormalities

No investigation is required if diagnosis appear to be simple back pain

General/Conservative: • Patient education, give information, reassurance and advice to stay active • Back stretches and exercises, group exercise programme or manual therapy • Physiotherapy , psychological support CBT • Discuss work and predisposing factors , identify yellow flags Medical • Regular pain relief – lowest dose, short course NSAIDs -> weak opioids • Consider short course of muscle relaxants (diazepam)

Disc Prolapse May be a result of mechanical or degenerative changes (lumbar spondylosis)

• Acute onset while lifting/bending • Severe pain • Pain eased by lying flat • Worse with moving and coughing • May have sciatica • Neurological symptoms – weakness, numbness (usually L5-S1 distribution) • May be overweight, occupation risk factors

• Back tenderness • Positive sciatic stretch test • Weakness in dorsiflexion (L5), sensory loss dorsum of foot • Weakness in plantar flexion, sensory loss posterolateral aspect of leg and lateral of foot (S1)

• Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP) – if suspect cancer, infection, inflammation, Paget’s • MRI – disc or impingement on nerves or spinal cord • CT – rule out stress fracture/spondylolisthesi s • X-ray – only good for fractures, Paget’s, collapse from osteoporosis/myeloma

Spinal Fracture Caused by trauma or vertebral collapse in osteoporosis

• Sudden onset of severe central spinal pain • Relieved by lying down • Hx of major/minor trauma

• Point tenderness over the vertebral body or pathological fracture

• X-ray – traumatic fracture, fragility fracture • CT lumbar • Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP) – if suspect cancer, infection, inflammation, Paget’s

Lumbar spinal stenosis Caused by disc prolapse or tumour or degenerative changes (OA)

• Back pain that is relieved by sitting/lying • Worse with standing, walking (esp. downhill) • B/l buttock to thighs burning/cramping pain • Neurogenic claudication – leg weakness/fatigue/ numbness

• Often normal • Pain may be present with lumber extension

• Lumbar X-ray – degenerative changes • MRI or CT myelography • Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP) – if suspect cancer, infection, inflammation, Paget’s

General/Conservative: • Patient education, reassurance, lifestyle changes – diet, weight, exercise • Advise stay as active as possible – back stretches and exercises • Group exercise programme or manual therapy • Physiotherapy if not resuming normal activities/off work • Psychological support – CBT • Chronic pain – identify yellow flags such as believing pain is harmful, extended rest, social withdrawal, emotional problems, dissatisfaction at work, problems with claims or compensation • Discuss work and predisposing factors – heavy lifting, ergonomic seating and posture Medical • Regular pain relief – lowest dose, short course NSAIDs, only offer weak opioids if NSAIDs ineffective, contraindicated or not tolerated • Consider referral to specialist pain clinic if pain unresolved • Consider short course of muscle relaxants (diazepam) Surgical • Discectomy +/- spinal fusion – referral to orthopaedic or neurosurgeon Conservative • Several weeks of bed rest • Physiotherapy, wearing a corset Medical • Pain relief Surgical • Vertebroplasty - minimal invasive • Spinal fusion with rehab General/Conservative • Weight reduction if overweight, exercise • Physiotherapy – forward flexion exercise Medical • NSAIDs or neuropathic pain relief – amitriptyline, gabapentin, pregabalin • Epidural injections with local anaesthetic +/- steroids Surgical • Laminectomy • Interspinous distraction procedure – reduces backward movement

ORTHOPAEDIC

Mechanical pain Non-specific pain originates from joints, bones or soft tissues around spine– may be due to minor sprain/strain

ORTHOPAEDICS BONE DISORDERS

Spondylolisthesis Anterior slippage of vertebrae due to spondylosis/ stenosis, pathologic, spondylolysis

• Exercise-related back pain • Radiate to posterior lower thighs • Eases by rest, esp in flexion • Aching in nature and insidious • Neurogenic claudication

• Neurological features in high severity cases • If lumbar stenosis present, reflexes may diminish

• Bloods – FBC, LFT, ESR, CRP, U+E, bone profile • Lateral spinal X-ray • CT/ MRI

Conservative • Complete bed rest 2-3 days, sleep on the side, pillow between knees • Activity modification – prevent further injury • Bracing/corset – if pars interarticularis fracture (likely to heal) • Physiotherapy – massage, bracing, mobilisation, exercises for flexibility and strength Medical • Pain relief – paracetamol, NSAIDs, codeine • Steroid and local anaesthetic injections Surgical • Spinal fusion of affected vertebra with neighbouring aligned vertebra • Cord/nerve decompression

Facet joint arthritis/ degeneration Part of lumbar spondylosis

• Low back pain worse by bending, standing, reaching upwards, walking down stairs/hills • Sitting forward/lying relieves pain

• Often normal • Pain on extension

• Lumbar X-ray – degenerative changes • MRI • Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP) – if suspect cancer, infection, inflammation, Paget’s

General/Conservative • Lifestyle modification – weight, exercise, diet • Physiotherapy, chiropractic treatment • Core trunk stability exercises, Pilates, yoga, aqua-aerobics Medical • Pain relief by NSAIDs, weak opioids, TENS • Facet joint injections - Local anaesthetic +/- steroids Surgical • Radiofrequency denervation – surgery rarely effective

Osteoporosis (vertebrae collapse/ fragility fracture)

• Worsening back pain • Reduced mobility and independence • Loss of height • Difficulty sleeping • Depression, GI sx

• Often normal

• CXR, ECG – for pre-op assessment • Bloods – FBC, blood group, coag, renal function, LFT, CRP, glucose, bone profile • Cognitive function • Lumbar X-ray

Fracture Management • Conservative – pain relief and physio for mobilisation • Surgical – vertebroplasty Conservative • Patient education, early physio and muscle strengthening exercises • Fall prevention measures • Modifiable risk factors – smoking, weight, alcohol, diet, exercise Medical • Assess risk of future fragility fracture Qrisk, FRAX– DEXA scan • Vitamin D and calcium • Bisphosphonate (alendronate PO or IV zoledronate) • Denosumab, raloxifene, teriparatide • HRT in younger perimenopausal women

Paget’s disease

• Usually asymptomatic • Bone pain at rest, at night, on movement but does not tend to be focused around a joint

• Skin temperature may be increased in active disease • Bone deformity

• Bloods – FBC, U+E, LFT (ALP), bone profile (Ca, Phosphate, PTH) • X-ray • Radionucleotide bone scans • Bone biopsy if suspect osteosarcoma (risk)

General/Conservative • Orthotic devices, sticks, walkers if affecting leg • Advice on calcium and vitamin intake Medical • NSAIDs and paracetamol • Bisphosphonate Surgical • Decompressive laminectomy – if compressing spinal cord

NEUROLOGICAL

Neoplasm Osteosarcoma Myeloma Metastases

• Onset in >50y or 30m • Insidious onset over months/years • Night pain • Gelling • Pain eases with movement • Worse after rest • Before age of 30 • During active disease – fever, malaise, weight loss • Peripheral enthesitis/ arthritis

• Tenderness over SIJ • Limited lumbar flexion, extension, lateral flexion • Schober test positive • Advance – loss of lumbar lordosis, exaggerated thoracic kyphosis (question mark posture) • Limited chest expansion

Cauda Equina Syndrome

SPONDYLOARTHROPATHY

Ankylosing spondylitis

• Unexpected laxity of the anal sphincter • Motor weakness and sensory deficit • Loss of reflexes if compressed on certain nerve roots

• Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP), bone profile(Ca) – if suspect cancer, infection, inflammation, Paget’s • X-ray, MRI, CT • Bone scan, biopsy • Tumour markers if suspecting bone mets • Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP), bone profile(Ca) – if suspect cancer, infection, inflammation, Paget’s • Blood culture • X-ray, MRI (IOC), CT • Bone biopsy and culture • Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP), bone profile(Ca) – if suspect cancer, infection, inflammation, Paget’s • MRI scan – IOC to confirm diagnosis, determine level of compression/cause • CT myelography • Urodynamic studies – monitor bladder function

• Bloods – FBC, ESR, CRP, urinalysis, LFT (ALP), bone profile(Ca) – if suspect cancer, infection, inflammation, Paget’s • HLA-B27, RF • X-ray (sacroiliitis, squared vertebrae, bamboo spine) • MRI – early sacroiliitis • CT • DEXA – risk of osteoporosis

Primary malignant • Referral to bone sarcoma centre • MDT care – complex • Chemotherapy/radiotherapy Metastatic cord compression • Steroids – dexamethasone to reduce oedema, monitor glucose, PPI cover • Decompressive surgery

Conservative • Rest, brace, physio Medical • Specialist/microbiologist advice on ABx – 4-6w for acute; 12w for chronic • Pain relief/fever Surgical • Bone and tissue debridement, correct deformity and preserve spinal stability • Decompression of cord +/- drainage of abscess Acute management • Refer immediately to neurosurgeon • Urgent surgical spinal decompression – prevent permanent damage Conservative (Post-op) • Lifestyle modification – obesity • Physiotherapy, OT – depending on residual lower limb symptoms Medical • Cord compression caused by malignancy – radiotherapy • CES caused by AS – steroids • Infection – Abx • Spinal neoplasms – chemo/radiotherapy Surgical • Lesion debulk – SOL such as tumour/abscess • Discectomy – if caused by herniated disc General/Conservative • Patient education and support groups • Referral to rheumatologist • Physio, OT for rehab, exercise programme, postural training, deep breath exercise • Exercises – swimming, hydrotherapy • Prevent complications – modify CVS risk factors – regular lipid checks, osteoporosis risk reduction – bisphosphonates Medical • NSAIDs to improve symptoms – PPI cover • Local steroids injection for symptomatic sacroiliitis or arthritis • TNF-alpha inhibitors effective in AS poorly controlled with NSAIDs • DMARDs – methotrexate/sulfasalazine may be useful Surgical • Vertebral osteotomy – prevent spinal deformities or total hip replacement if affected...