differential diagnosis

BACK PAIN... What else could it be?

Martin Melbye PT Dip MDT

Possible diagnoses?

Visceral causes

ABDOMINAL

gall stone

kidney stones

infections

tumours

GYNECOLOGY

cysts/tumours

fibroma

infections

ectopic pregnancy

UROGENITAL

infection

prostate

rED FLAGSAge < 20 or >55

Non-mechanical pain

Night pains

Previous cancer, steroid use

Weight loss

Bad general condition

Thoracic pain

Trauma

“Harry”

68 year old

Back and bilateral leg pain

Symptoms for 12 months

Spinal Stenosis

Spinal stenosis

Subjective history findingLikelihood of stenosis after a negative responseStenosis prevalence 2%

Likelihood of stenosis after a negative responseStenosis prevalence 13%

1) Pain below the buttock? 0,67 % 4,97 %

2) Age over 65 years? 0,22 % 1,7 %

3) Symptoms relieved by sitting? 0,06 % 0,48 %

4) Symptoms provoked by walking? 0,02 % 0,16 %

“Victor”

24 years old

Low Back and bilateral buttock pain

Spondylolisthesis

Spondylolisthesis

21 out of 936 asymptomatic individuals had spondylolistesis (Libson 1982)

Spondylolisthesis associated with 25% greater risk of LBP (Grosser 1996)

Spondylolisthesis

X-Ray to exclude

Functional X-Ray to determine instability

MRI to examine nerve root affection

“Matt”

37 years old

Severe back pains

Disturbed sleep, wakes up towards the morning.

Difficult to take care of work as a banker

Back feels stiff

Very tired

Slow onset

Improves when gardening

Inflammatory Back pain

4 out of 5:

Onset of back pain before the age of 40.

Insidous onset.

Improves after activity.

No improvement with rest.

Night pains that eases when the patients gets out of bed.

Family history

Psoriasis

Crohns/Collitis

HLAB-27

“Tendinitis”

Swollen finger/toe

Blood tests

Inflammatory Back pain

Less than10/12 cm

Inflammatory Back pain

STIR MRI

“lizzy”

78 years old

Acute onset back pain 4 days ago while gardening

Constant pain

Radiating into the thigh

Osteoporotic fracture

Sudden onset

Direct pain on vertebrae

Worse with walking, standing, sitting, moving

XRAYS - DEXA-scan

Osteoporisis - Risk

Woman (every 3rd woman, every 8th male)

Early menopause (<45 years)

Family history

Steroid treatment >5 mg daily and/or more than 3 months

Tobacco/alcohol use

Low body weight

“Eric”

52 year old cab driver

Sharp back pain for 1 month

Radiating into left thigh

Constant pain

“Eric”

Pain on percussion of vertebrae

Bad general condition

Severe pain in left groin

Sweating

Infection

Generally unwell

Previous infection or surgical procedure

Discitis or Epidural abcess

PSOAS ABCESS

“Eliza”

70 years old

Low Back Pain 4 months ago

Slow onset, no specific cause

No previous back pain episodes

WHATS YOUR PLAN?

Age

Previous history

General health

Blood tests

Infection, inflammation

Affection of kidney or urinary system

Bones (fracture, inflammation, cancer)

Prostate

Other

Spinal tumours

Most often metastases 25:1

Chest, prostate, lungs, kidney, colon.

Thoracic pain

Night pains

Constant pain

Weight loss 5-10% over 3-6 months

Xrays - MRI

Individuals WITH NO symptoms

Stenosis 21 %

Spondylolisthesis 2 %

Disc prolapse 36 %

“Degenerative changes” 80 %

Remember this...