eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Back Pain, Mechanical: Differential Diagnoses & Workup

Author: Debra G Perina, MD, Associate Professor, Director of Prehospital Care Division, Department of Emergency Medicine, University of Virginia Health Sciences Center
Contributor Information and Disclosures

Updated: Jul 16, 2009

Differential Diagnoses

Aneurysm, Abdominal
Pelvic Inflammatory Disease
Appendicitis, Acute
Perirectal Abscess
Ectopic Pregnancy
Prostatitis
Endometriosis
Renal Calculi
Neoplasms, Spinal Cord
Urinary Tract Infection, Female
Ovarian Cysts
Urinary Tract Infection, Male

Other Problems to Be Considered

Perforated viscous
Pancreatitis
Large bowel obstruction

Workup

Laboratory Studies

  • Consider performing urinalysis if the problem is not clearly musculoskeletal or an exacerbation of chronic back pain.
  • Perform a complete blood count (CBC) and erythrocyte sedimentation rate (ESR) if the patient is febrile or if an epidural or spinal abscess, or osteomyelitis is suspected. While ESR has moderate specificity, the sensitivity is relatively high in cases of abscess, and it can be used as a screening test.
  • Other laboratory studies are rarely needed unless a disorder other than back pain is strongly suspected.

Imaging Studies

  • Radiography
    • Lumbosacral spine series are expensive and expose the reproductive organs to significant radiation. Annually, 7-8 million such tests are obtained, but most have little value in directing therapy, particularly among adults younger than 50 years.
    • Unless a history of traumatic injury or systemic illness is present, such films should be obtained only for suspicion of malignancy or infection. Malignant involvement of vertebral bodies can be evident on plain film when as little as 30% of the vertebral body has been replaced.
    • Other indications that suggest the need for radiographic imaging include chronic steroid use and acute onset of pain in patients older than 50 years or in the pediatric age group.
    • The physician may also consider obtaining radiographs in patients whose cases involve (or potentially involve) litigation or for patients seeking compensation.
  • CT and MRI12
    • CT and MRI are generally considered the studies of choice for more precise imaging of the vertebrae, paraspinal soft tissues, discs, or spinal cord. CT images cortical bone with higher resolution and can delineate some fractures better than MRI.
    • MRI is generally the preferred imaging modality for detecting disc, cord, or soft tissue abnormalities.
  • Ultrasonography may be useful if the differential diagnosis includes appendicitis, a pathologic pelvic process, or abdominal aneurysm.
  • True emergencies that necessitate imaging include the following:
    • Patients with a history of malignancy and new evidence of nerve entrapment
    • Patients with back pain associated with paralysis or gross muscle weakness
    • Patients with bilateral neurologic deficits associated with bowel or bladder function loss
    • Patients in whom an epidural hematoma or epidural abscess is suspected
    • Postoperative patients with a recent lumbar laminectomy or hip replacement

Improvement occurs in almost all patients within 4-6 weeks, except those with infection, occult malignancy, or systemic illness. If pain fails to significantly improve or resolve in this time frame, imaging is always indicated.13

Other Tests

  • Perform the straight leg raising test with the patient in a supine position. Record the response to raising each leg. An approximation of the test may be performed with the patient sitting and each leg straightened at the knee. The examiner should take care to make sure that the quadriceps muscle is relaxed while passively raising the leg to ensure that the sciatic nerve is being adequately stretched during the testing. If the quadriceps is contracted, it will take the pressure off the sciatic nerve and may give a false-negative result.
  • The stoop test helps distinguish true claudication from pseudoclaudication. Patients with true claudication sit down to rest when pain occurs, while patients with pseudoclaudication attempt to keep walking by stooping or flexing the spine to relieve the stretch on the sciatic nerve.

More on Back Pain, Mechanical

Overview: Back Pain, Mechanical
Differential Diagnoses & Workup: Back Pain, Mechanical
Treatment & Medication: Back Pain, Mechanical
Follow-up: Back Pain, Mechanical
References
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References

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Further Reading

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Keywords

low back pain, mechanical low back pain, low back pain treatment, low back pain causes, musculoligamentous injury, classic nerve root syndrome, musculoskeletal pain syndrome, impingement syndrome, herniated disk, herniated disc, spinal degeneration, cauda equina syndrome, myofascial pain syndrome, fibromyalgia, osteomyelitis, sacroiliitis, spinal stenosis, degenerative joint disease, straight leg test

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Contributor Information and Disclosures

Author

Debra G Perina, MD, Associate Professor, Director of Prehospital Care Division, Department of Emergency Medicine, University of Virginia Health Sciences Center
Debra G Perina, MD is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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