Differential Diagnosis for the Spine

Question 1

Most Common Red Flags for systemic origin of LBP

Answer 1

Age 50
previous history of cancer
constitutional symptoms-fever, chills, weight loss more than 10lbs unexplained wt. loss
Recent UTI
History of injection drug use
Immunocompromised-steroids, transplant, HIV
Night Pain or Pain that is worse at night…pt. must get up at night to relieve pain
Failure to improve with conservative care 4-6 weeks
Pain not relieved by rest or recumbency
Severe constant night pain
progressive neuro deficit; saddle anesthesia(cauda equina)
LBP with abdominal, pelvic or hip pain
History of falls or trauma
significant am stiffness with all AROM limited
Skin Rash–inflammatory disorder, chrones disease

Question 2

Referred Pain

Answer 2

The term referred pain isused to describe those symptoms that have their origin at a site other than where the patient feels pain.

Referred pain–pain of somatic origin that is perceived as musculoskeletal pain.

Question 3

Referred pain can be generated by

Answer 3

Convergence of sensory input from separate parts of the body to the same dorsal horn neuron via primary sensory fibers
Secondary Pain resulting from a myofacial trigger point
Sympathetic activity elicited by spinal reflex
Pain generating substaces–substance P, bradykinin, histamine

Question 4

Systemic Pain

Answer 4

Onset=recent, sudden
Description= sharp, deep ache, inside out, unilateral or bilateral
Intensity=mild to severe, not affected by anxiety
Duration= constant, unchanging, awakens at night
Pattern=gradual progression, no change with rest
Aggravating factors=can’t relieve, provoke, eliminate symptoms; origin dependent
Relieving Patterns= organ dependent; lying on side-kidney
sitting up-pancreas
Associated S&S=fever, chills, night sweats, changes in vital signs, GI symptoms, dyspnea, HA, skin rash, diaphosresis,
B/B (bowel and bladder) S&S, dizziness, bilateral edema, weakness

Question 5

Musculoskeletal Pain

Answer 5

Onset= May be sudden (acute) or gradual (chronic)
Description= local tenderness, throbbing, pain decreasing with rest, unilateral
Intensity= mild to severe>worse
Duration= typically intermittent, varies with activity/rest/position
Pattern=Decreases in motion AROM, PROM, accessory
Aggravating factors=altered with movement-better or worse
Relieving Factors= rest, position, changes, stretching, heat and cold
Associated S&S= none except with severe pain-nausea, sweating

Question 6

Referred Pain has reccommended classifications

Answer 6

Viscerogenic
Vasculogenic
Neurogenic
Psychogenic
Spondylogenic

Question 7

1. Viscerogenic Pain

Answer 7

viscerogenic pain may be produced when the nociceptive fibers from the viscera synapse in the spinal cord with some of the same neurons that receive pain from the skin
–diffuse pain–poorly localized
pleura, pericardium-more specific, sharp pain

Question 8

Heart (T1-T5) and Bronchi and lungs (T2-4)

Answer 8

pain referred deep to the sternum, neck shoulders, pectoralis muscles, UE L>R

Question 9

Esophagus T5-T6

Answer 9

Pharynx, neck, UE’s, sternum

Question 10

Gastric (T6-T10)

Answer 10

Lower thoracic to abdomen

Question 11

Gallbladder (T7-T9)

Answer 11

Upper abdomen, lower scapula and thoracolumbar

Question 12

Pancreas

Answer 12

upper L/S, upper abdomen

Question 13

Bladder (T11-T12)

Answer 13

Lower abdomen or L/S

Question 14

Uterus

Answer 14

Lower abdomen or L/S

Question 15

Kidneys (T10-L1)

Answer 15

Upper L/S, lateral to navel

Question 16

Viscerogenic Pain has 5 important clinical characteristics

Answer 16

1. It is not evoked from all viscera
2. It is not always linked to visceral injury
3. It is diffuse and poorly localized
4. It is referred to other locations
5. It may be accompanied with autonomic, reflexes, such as the nausea and vomiting

Question 17

Vasculogenic Pain

Answer 17

1. Vasculogenic pain tends to result from venous congestion or arterial deprivation to the musculoskeletal areas
2. Tends to mimic a wide variety of musculoskeletal, neurologic, and athritic disorders, as this type of pain is often worsened by activity
   (the skin will tun dark and purple/red it will be shiny
   If you put them on a bike the symptoms will be worse as the vasculogenic problem will be exacerbated)

Question 18

Neurogenic Pain

Answer 18

Neurogenic pain is pain that is referred from a neurological structure.
Neurogenic causes of pain may include
–a tumor compressing and irritating a neural structure of the spinal cord, meninges
–a spinal nerve rood irritation
–peripheral nerve entrapment
–neutritis

Question 19

Psychogenic Pain

Answer 19

Psychogenic Pain (non-organic) is characterized by abnormal illness behaviors
Commonly exhibited by patient's suffering from depression, emotional disturbance, or anxiety states
All patients should be given the benefit of the doubt until clinical, with a high degree of confidence, can rule out an organic cause for the pain.

Question 20

Spondylogenic Pain

Answer 20

Spondylogenic pain is pain referred from a vertebral lesion
-Characteristics of a spondylogenic lesion include
=Severe and unrelenting pain
-The presence of a fever
=Bone tenderness
-Unexplained weight loss

Question 21

Generalized Body Pain

Answer 21

2 conditions that can cause generalized body pain (psychogenic type pains)
Fibromyalgia
Myofacial pain Syndrome

Question 22

Causes of Cervical Pain

Answer 22

Cardiac Disease
Trauma
Tumor–tumors of the adult cervical spine may be primary, arising from the bone, or secondary
Temporomandibular Dysfunction
Meningitis
Cervical Disk disease
vertebral artery disorder
Torticollis
Rheumatoid Arthritis
–cervical spine involvement is common in rheumatoid arthritis
Ankylosing Spondylitis
–Ankylosing spondylitis commonly affects the C1-C2 segment (ALL and Vertebral disc begin to calcify—pain in all directions–men more then women) over time the spine begins to fuse(treat with caution after the fusion happens
Gout
–althought the occurrence of gout in the neck is distinctly uncommon, the medications used to treat it can have serious side-effects in this region
———allopurional causes joint pain and HA
Osteoarthritis
Occipital Neuralgia

Question 23

Causes of Thoracic Pain

Answer 23

Gastrointestinal conditions
Pancreatic Carcinoma
Mediastinal tumors–although primary tumors of the thoracic spine are rare, the thoracic spine is the most common site for metases
Myocardial infarction
Pleuropulmonary conditions
thoracic disk
vertebral or rib fracture
intercostal neuralgia
costochondritis (inflammation of the catilage where the ribs attach to the sternum)
osteoarthritis
rheumatoid arthritis
ankylosing spondylitis (arthritis that causes constant inflammation of the spine)
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
—characterized by an ossification of the anterior longitudinal ligaments and all related, anatomically similar ligaments
Manubrium-sternal dislocations

Question 24

Causes of Lumbar Pain

Answer 24

Strain or sprain
renal disorder
Epidural abcess
Prostatitis (inflammation of prostate gland)
Pleural dysfunction
Aortic Dysfunction
Metastasis
Ankylosing Spondylitis
Stiff-Person Syndrome---disabling neuro disorder with rigidity

Question 25

Causes of Sciatica

Answer 25

DISCOGENIC=Discogenic pain is pain originating from a damaged vertebral disc, particularly due to degenerative disc disease. However, not all degenerated discs cause pain
-Disc herniation
-lateral entrapment (stenosis)
NONDISCOGENIC
-sacroilitis (inflammation of sacroiliac joint)
piriformis syndrome
trochanteric bursitis
Ischiogleutal bursitis
Posterior facet syndrome
fibromyalgia
SYSTEMIC ORIGINS--clinical S&S may be similar
---vascular
---------ischemia to sciatic nerve
-------Peripheral Vascular Disease
-------intrapelvic aneurysm
---Neoplasm-primary or metastic
---Diabetic neuropathy
---Pregnancy--vaginal delivery
---THA (total hip arthroscopy)
---Infection
-----Bacterial endocarditis/herpes zostar (shingles)/psoas muscle abcess
--Endometrosis
---DVT (deep vein thrombosis)

Question 26

Mechanical LBP–Compression fracture

Answer 26

• ->65 years of age female>male
• -commonly at mid T/S and mid L/S
• -acutely painful, especially with flexion

Question 27

Mechanical LBP–Vertebral Stenosis

Answer 27

Insidious onset that is progressive
Typically >50, males>females
Bilateral Pain, worse with extension and weight bearing
See postural changes, decrease lordosis
(live in a posterior pelvic tilt as a modification of their posture)

Question 28

Mechanical LBP–Disc Disease

Answer 28

30-50YO worse with sitting, better with walking to a point
HNP (herniated nucleus propulsis) commonly at L4/L5 and L5/S1 typically posteriolateral
LBP that progresses to sciatica, may have lateral shift, decrease lordosis
+ thecal signs::coughing, sneezing, +SLR, +well leg SLR

Question 29

Mechanical LBP Sprain

Answer 29

< 30yo, typically with flexion and rotation
unilateral LBP, no redicular pain, but can refers into gluteal and posterior thigh
Pain with SB and rotation away from side of pain

Question 30

Mechanical LBP-Facet Syndrome-Facet Syndrome

Answer 30

May occur with trauma, disc degeneration, posture changes
Pain Referred to gluteal and posterior thigh
Muscle guarding, pain with extremes of motion,
PAIVM’s(passive assisted intervetebral muscle testing)
Spondylolisthesis