Back Pain and Spinal Disorders Quiz

Back Pain Differential Diagnosis

• Clinical presentation of insidious onset of back pain, gradually increasing in severity, aggravated by activity and lying down, and may occur anywhere in the spine.
• Bony metastasis is suggested by worsening with activity, lack of relief on lying down, atypical location, and focal spinous tenderness.
• Epidural invasion manifests as increasing back pain followed by neurologic symptoms, upper motor neuron signs, sensory loss, and autonomic dysfunction.
• Intraspinal tumors may present similarly to herniated disks, but marked progression of neurologic deficits despite conservative therapy indicates a tumor.
• Extraspinal tumors may cause root impingement and simulate discogenic sciatica, with metastases occurring earlier.
• Infections causing back pain are rare but important to detect, with identifiable sources found in 40% of cases.
• Vertebral osteomyelitis is usually hematogenous and may extend into the disk space, producing painful discitis.
• Epidural abscess develops in the context of bacteremia or osteomyelitis and presents as back pain, focal tenderness, and fever.
• Patients with depression may present with chronic low back pain, often amplifying the presentation and prolonging the clinical course.
• Cauda equina syndrome presents with urinary retention in almost 90% of cases, saddle anesthesia in about 75% of patients, and lower extremity motor and sensory deficits.
• Piriformis syndrome causes sciatic nerve pain due to compression by the piriformis muscle, with focal pain in the midbuttock and tenderness in the sciatic notch.
• The vast majority of back pain cases (97%) are mechanical in origin, with less than 1% due to infection, neoplasia, or inflammatory disease, and about 2% representing referred pain from visceral disease.

Spinal Disorders and Conditions: Key Points

• Spinal stenosis is characterized by pain exacerbated by standing and walking, relieved by rest and flexing the spine and hips
• Symptoms can mimic vascular insufficiency and are sometimes referred to as "pseudoclaudication" or "neuroclaudication"
• The natural history of spinal stenosis is generally favorable, with only 15% of patients reporting clinical worsening over 5 years
• Spondylolisthesis in adults results from degenerative changes and arthritis of the facet joints, usually at L4 to L5 or L5 to S1, with 10% to 20% forward slippage
• Ankylosing spondylitis is the most common seronegative spondyloarthropathy and is characterized by low back pain of at least 3 months' duration, improvement with exercise but not with rest, and bilateral sacroiliitis or severe unilateral disease
• Vertebral compression fractures are acutely painful and are most commonly seen in elderly persons with severe osteoporosis, patients taking long-term glucocorticoids, and cancer patients with lytic bony metastases
• Metastatic carcinoma is the most common spinal tumor, with breast, lung, prostate, gastrointestinal, and genitourinary neoplasms commonly metastasizing to the spine
• Myeloma is the most common primary bone tumor involving the spine, typically affecting individuals older than 50 years
• Metastasis to the spine is hematogenous to the marrow of the vertebral bodies, leading to pain and potential neurologic deficits
• Approximately 90% of individuals with metastatic disease as the cause of back pain report night pain and pain unrelieved or worsened by lying down or bed rest
• Neoplasms in the spine can lead to spinal cord compression and vascular compromise, contributing to cord injury
• A history of prior malignancy, insidious increase in pain in a region atypical for disk disease, and failure to obtain relief by lying down are highly predictive of metastatic tumor