BACK PAIN
BACK PAIN: Excerpt from Algorithmic Diagnosis of Symptoms and Signs
Ask the following questions:
- Is the pain of acute onset or gradual onset? If it is acute onset, one must consider the possibility of epidural abscess, pyelonephritis, or other abdominal conditions as the cause of the back pain. If it is gradual onset, one should consider that it may be a tumor, particularly of the spinal cord or cauda equina, a pelvic tumor, or an aortic aneurysm that is compressing one of the nerve roots. In addition, chronic conditions such as lumbar spondylosis, rheumatoid spondylitis, and prostatitis must be considered.
- Is there a history of trauma? If there is a history of trauma, one should consider a compression fracture of the spine, a sprain or herniated disk, as well as spondylolisthesis. Without a history of trauma, one should consider a tumor, herpes zoster, or dissecting aneurysm. Lumbar spondylosis might be silent for a while only to cause pain after a significant traumatic event.
- Is there radiation of the pain around the trunk or into the extremities? Radiation of the pain would certainly be more likely to signify a space-occupying lesion of the spinal column such as a tumor, an epidural abscess, or a herniated disk. If there is no radiation, one would consider osteoarthritis or lumbar spondylosis and rheumatoid spondylitis.
- Finally, are there bladder symptoms associated with the pain? If there are, then one must consider the possibility of a spinal cord tumor, cauda equina tumor, or kidney disease.
DIAGNOSTIC WORKUP
All patients with back pain need to have a CBC, urinalysis, and probably a urine culture, as well as a chemistry panel. A sedimentation rate should be done if rheumatoid arthritis is suspected. All patients should also have plain x-rays of the thoracic and/or lumbar spine. It is very important to get anterior posterior views, as well as oblique and lateral views. At this point it is wise to observe the results of conservative therapy before ordering expensive diagnostic tests. If there is doubt about the diagnosis at this point, a neurologic or orthopedic specialist may be consulted. If there is radiation of the pain into the extremities or around the trunk and definite neurologic findings, one should proceed to a CT scan or MRI immediately. The CT scan costs about half as much as the MRI and usually will show any significant herniated disks, primary or metastatic tumor. Even without radiation of pain into the extremities or definite neurologic findings, a patient with persistent back pain should have a CT scan or MRI. EMG will be useful in identifying radiculopathy.
When all these studies are negative, it might be wise to get a bone scan because this will show the increased uptake of the sacroiliac joints in rheumatoid spondylitis. Also, one should test for the HLA B27 antigen. In the event that all of the above studies are negative, the possibility of a non-neurologic condition or nonorthopedic condition causing the back pain should be considered. Perhaps abdominal ultrasound should be done to rule out an aortic aneurysm. Perhaps a pelvic tumor or prostatic tumor should be reconsidered. Perhaps there is a pancreatic tumor that is causing the back pain. Occasionally, combined myelography and CT scan is the only way to identify a lesion. Exploratory surgery is rarely necessary. Older patients should have a serum protein electrophoresis (for multiple myeloma) and acid phosphatase or PSA to rule out prostatic carcinoma.
Book Source Details
- Book Title: Algorithmic Diagnosis of Symptoms and Signs
- Author(s): R. Douglas Collins
- Year of Publication: 2003
- Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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