Differential diagnosis of spondylolysis in a patient with chronic low back pain jill theinnissenbaum, mpt, scs, atc1 william g. Jan 14, 2016 cardinal presentations this post is part of a series called cardinal presentations, based on rosens emergency medicine 8th edition. Among asymptomatic individuals, 20% to 30% have evidence of a herniated disk on computed tomography ct or mri. Apr 01, 2016 low back pain lumbar back pain is defined as pain in the back from the level of the lowest rib down to the gluteal fold, with or without radiation into the legs 5. The differential diagnosis of low back pain wiley online library. Despite the availability of modern diagnostic tools, the cause of the pain generator is often unidentifiable. Low back pain lbp is the most common musculoskeletal condition affecting the adult population, with a prevalence of up to 84% 1. Back pain is a common presentation to the emergency department.
Table 1 presents the differential diagnosis of acute low back pain. Back pain is the most common cause of shortterm disability in adults younger than 45 years and the. Displaying differential diagnosis of low back pain powerpoint presentations advanced imaging for low back pain 869473 ppt presentation summary. Signs and symptoms the list of differential diagnoses for lower extremity pain is extensive and broad.
Lower extremity pain clinical guidelines for workup. According to jarvik and deyo,23 in approximately 7% to 8% of patients with lbp, the cause is due to nonmechanical spinal conditions or visceral disease. Differential diagnosis of low back pain n mechanical low back or leg pain 97% n lumbar strain, sprain 70% n degenerative processes of disks and facets, usually agerelated 10% n herniated disk 4% n spinal stenosis 3% n osteoporotic compression fracture 4% n spondylolisthesis 2% n traumatic fracture low back pain has a lifetime prevalence of approximately 80%. Low back pain and differential diagnosis 2019 back pain help. Sciatica is radiating, lower extremity pain and may not be associated with back pain. Nov 01, 2010 therefore with bilateral spondylolysis or bilateral fractures the vertebral pedicle slips anteriorly.
Be sure to keep in mind the red flags for back pain. With spondylolysis or spondylolisthesis, the patient will usually complain of increased pain with hyperextension of the lower spine. Most commonly, diagnoses of acute painful spinal conditions are nonspecific, such as neck or back strain, although injuries may affect any of several pain sensitive structures, which include the disk, facet joints, spinal musculature, and ligamentous support. Low back pain online medical reference from definition and diagnosis through risk factors and. Feb 15, 2012 low quality evidence shows that in the first five days of acute low back pain, the use of heat treatments may be more effective for reducing pain and disability than nonheat wraps, nsaids, or. Low back pain is the commonest cause for years lived with disability.
Pearl major serious causes of back pain crafti cauda equina renal aorta aneurysm or dissection fracture infection workup labs usually low yield ua low threshold especially in female patients uti cbcchem 10 type and cross for 8 unitsemergency release blood if suspecting aaa esrcrp elevated in epidural abscess imaging bedside ultrasound. Low back pain caused by fragility fractures in osteoporosis patients has been found to have the most signi. An episode of low back pain is called acute if it has arisen for the first time in a patients life, or after a pain free interval of at least six months, and lasts no longer than. Figure 71 reorganizes the differential diagnosis using pivotalpoints and outlines the diagnostic approach to low back pain. Terminology used in spine disc pathology and back pain differential diagnosis of low back pain risk factors for osteoporosis solitary nerve root lesions of the lumbosacral spine neurogenic vs vascular claudication manifestations of oa nonorganic low back pain signs waddell acp best practice advice lower back pain cancer tests for back pain. In up to 85% of individuals, no specific cause can be isolated.
Mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the united states accounting for more than 6 million cases annually. Pdf differential diagnosis of low back pain researchgate. Here we discuss about radicular pain, facet joint pain, sacroiliac pain, pain related to lumbar stenosis, discogenic pain. Low back pain, without symp toms or signs of serious. The etiological characterization of low back pain is a process that requires a propaedeutic approach that includes the clinical history. Low back pain is usually categorized in 3 subtypes. Differential diagnosis of low back pain article pdf available in seminars in pain medicine 23. The most important issue for emergency physicians is to be able to. Differential diagnosis of low back pain sciencedirect. The recommendation on application of heat for shortterm relief of acute low back pain is based on expert opinion in several us clinical practice guidelines such as diagnosis and treatment of low back pain. Imaging has limited utility because most patients with chronic low back pain have nonspecific findings on imaging studies,7 and asymptomatic patients often have abnormal 6findings. Low back pain that has been present for longer than three months is considered chronic, although there is still no consensus about the definition of clbp. Acute low back pain acute low back pain is a common presenting illness in the primary care setting family physicians generally see at least one presentation a week. Low back pain has a lifetime prevalence of approximately 80%.
Be able to formulate a differential diagnosis for lower back pain based on the history. The first step implies examining the presence of neuropathic low back pain. Nov 27, 2018 low back pain online medical reference from definition and diagnosis through risk factors and. Low back pain lbp is the fifth most common reason for physician visits, which affects nearly 6080% of people throughout their lifetime. Back pain is the primary cause of disability in people low back pain lbp is second only to upper respiratory problems for physician visits each year, with a lifetime prevalence of 70% to 85%. In patients with positive findings, the initial patientspecific differential is quickly limited.
However, acute low back pain occurs frequently, and many of the conclusions of these guidelines remain relevant. Low back pain academy of orthopaedic physical therapy. There was good tone and strength, with normal deep tendon reflexes and normal sensation in the lower extremities. Medications do not relieve the constant dull ache or the intermittent sharp. Differential diagnosis of low back pain n mechanical low back or leg pain 97% n lumbar strain, sprain 70% n degenerative processes of disks and facets, usually agerelated 10% n herniated disk 4% n spinal stenosis 3% n osteoporotic compression fracture 4% n spondylolisthesis 2% n traumatic fracture low back pain in the primary care setting. See table 1 for the differential diagnosis for low back pain. It is concluded that low back pain, a disease of the. Different than sleepnight pain this will hurt rest sitting with hands in lap usually rapidsudden onset 1010 pain out of clear blue sky may start soon after an event or recent incr. Differential diagnosis of a patient referred to physical.
Nonspecific low back pain is common and usually selflimited. Diagnosis is made by eliminating specific lower back pain causes of neurological compromise, neoplasia, inflammatory arthritis, fracture, or referred pain from other locations or organ systems. This subdivision is based on the duration of the back pain. Diagnosis and treatment of acute low back pain american. The treatment of acute, subacute, and chronic low back pain are discussed separately. Differential diagnosis of spondylolysis in a patient with. Statement of intent these guidelines are not intended to be construed as or to. Patient strained lower back unloading a truck, which required lifting heavy boxes, twisting and placing boxes on flats three years ago. Nov, 2014 the issue of low back pain lbp is as common as it is perplexing. These structures may be causing direct or referred pain patterns. It is estimated that up to 84 percent of adults have low back pain at some time in their lives 1,2. Low back pain lbp is posterior trunk pain between the ribcage and the gluteal folds. Identify appropriate investigations and referrals for an individual complaining of lower back pain. Next, the differential diagnosis between predominant nociceptive and central sensitization pain is done using a clinical algorithm.
Thus it will provide a comprehensive approach to differential diagnosis and management of low back pain. The annual incidence in the adult population is 10% to 15% with a point prevalence of approximately 30% in developed countries. It is the fifth most common reason for all physician visits in the us. May 25, 2018 differential diagnosis for abdominal pain based on history and physical examination in spite of the fact that area of stomach pain or abdominal pain directs the underlying assessment, related signs and indications are prescient of certain reasons for pain in the abdomen and can limit the differential diagnosis. Approximately two thirds of adults are affected by mechanical low back pain at some point in their lives, making it the second most common complaint in ambulatory medic. The discussion in this article is extensive but not all. Musculoskeletal lower back pain differentials bmj best. There are published guidelines for the diagnosis and treatment of low back pain. Lbp is thought to be a chronic issue in approximately 10% of the u. The icd diagnosis of low back pain low back strainlumbago and the associated icf diagnosis of acute or subacute low back pain with related cognitive or affective tendencies are made with a reasonable level of certainty when the patient presents with the following clinical findings 112, 124, 6, 183, 318. Oct 10, 2011 onset of ripping or tearing back pain, saddle anesthesia, represents an acutely herniated disc, needs an emergent mri for diagnosis, managed emergently in the or epidural abscess iv drug user with fever and back pain, also in diabetics or patients with recent epidural injections, needs an emergent mri for diagnosis. It also includes lower extremity pain that results from a low back disorder sciaticaradiating low back pain, whether there is trunk pain or not. Specific causes of lbp are uncommon, and in approximately 90% of patients a specific generator cannot.
Because of the weak associations among symptoms, physical findings, imaging results, and electromyograms, a majority of patients with low back pain. A 26yearold male sought physical therapy services via direct access secondary to a flareup of a chronic low back pain condition. Differential diagnosis of low back pain ppt xpowerpoint. However, between 38% and 52% of asymptomatic individuals demonstrated significant lumbar disc bulging on mri. Instructional course lecture differentiating hip pathology. Evaluation of back pain differential diagnosis of symptoms bmj. The etiology of low back pain may be difficult to determine at times because of the number of diverse anatomic structures located in or near the low back region. Many authors suggest defining chronic pain as pain that lasts beyond the expected period of healing, avoiding this. The issue of low back pain lbp is as common as it is perplexing. Because of the increased pain with hyperextension, the physician thought that this could be a spondylolysis but the radiologic evaluation of lower spine radiographs were negative.
Some of the numerous causes of back pain are listed in table 4. In every patient with back pain, it is essential to systematically ask about and look for the clinical clues and pivotal points associated with serious causes of back pain. Chronic lbp clbp is a chronic pain syndrome in the lower back region, lasting for at least 12 weeks 2. An accurate diagnosis is essential for both acute and chronic low back pain conditions. When caring for a patient and developing a back pain differential diagnosis, remember to consider age, the history, physical exam findings, laboratory results, and imaging if needed. You are annoyed when your back is examined because it is painful. Lower back pain is now a days common in males, especially in 50 or more than 50 years old males. The most common form of low back pain is the one that is called nonspecific low back pain and is defined as low back pain not attributed to recognizable, known specific pathology. Suspicion of such back pain causes would warrant the physical therapist referring the patient to a physician.
Any innervated structure in the lumbar spine can cause symptoms of lbp. Initial imaging with mri, which is the preferred study, or ct is only rec. A history of startup groin pain ie, pain that usually improves after 5 to 10 steps and then gradually returns may indicate a loose total hip arthroplasty tha component. The vast majority of patients seen in primary care 85 percent will have nonspecific low back pain, meaning that the patient has back pain in the absence of a specific underlying condition that can be reliably identified 35. Feverweaknesssyncopealtered mental statusseizuredizziness and vertigoheadachesore throatdyspneachest painabdominal painnausea and vomitinggastrointestinal bleedingacute pelvic painback pain causes of back pain key historical findings onset acute onset. Low back pain lumbar back pain is defined as pain in the back from the level of the lowest rib down to the gluteal fold, with or without radiation into the legs. Lumbar 5th vertebra, lumbosacral transition, sacralization view fulltext.
Always be familiar with the childs medical history focused history of musculoskeletal pain timing of. The discussion in this article is extensive but not allinclusive, and the clinician should consult other sources for more detailed description of the less common differential diagnoses. Diagnosis and treatment of acute low back pain aafp. Pain, stiffness, andor soreness of the lumbosacral. Nonspecific back pain most people more than 85 percent have what doctors call nonspecific low back pain, which means that the pain is not clearly caused by a specific disease, abnormality, or serious injury of the spine. It is associated with disability, health care expenses, and a loss of wages and productivity. Explain the preliminary differential diagnoses and initial workup plan to the patient. A thorough history and physical exam will aid the provider in identifying the correct diagnoses. Startup back or buttock pain may indicate spinal instability. Learning point the differential diagnosis of back pain in children includes. In rosens emergency medicine concepts and clinical practice 8th ed.
An episode of low back pain is called acute if it has arisen for the first time in a patients life, or after a painfree interval of at least six months, and lasts no longer. The etiological characterization of low back pain is a process that requires a propaedeutic approach that includes the clinical history, physical and complementary exams. In every patient with back pain, it is essential to systematically ask about and look for the clinical clues and pivotal points associated with serious causes of back pain table 71. Differential diagnosis for abdominal pain based on history and physical examination in spite of the fact that area of stomach pain or abdominal pain directs the underlying assessment, related signs and indications are prescient of certain reasons for pain in the abdomen and can limit the differential diagnosis. Chronic pain, differential diagnosis, low back pain, neurostimulation.
A case study department physical therapy degree doctor of physical therapy in presenting this scholarly project in partial fulfilhnent of the requirements for a graduate degree from the university of north dakota, i agree that the department of physical therapy shall make it freely available for inspection. Jan 24, 2017 mechanical low back pain is one of the most common patient complaints expressed to emergency physicians in the united states accounting for more than 6 million cases annually. Low back pain lbp is a common reason for office appointments in the united states, accounting for 2% of all visits. Be able to outline a plan for managing both acute and chronic lower back pain. Low back pain is the leading cause of long term disability worldwide. Assessment of back pain differential diagnosis of symptoms. When the examinee enters the room, sit on the edge of the examination chair and try to. Lower back pain persists on a daily basis and increases with bending and twisting. People sometimes refer to throwing out their back, meaning they had suddenonset pain following physical activity.
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