Differential Diagnosis for the Spine Flashcards
Most Common Red Flags for systemic origin of LBP
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
Referred Pain
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.
Referred pain can be generated by
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
Systemic Pain
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
Musculoskeletal Pain
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
Referred Pain has reccommended classifications
Viscerogenic Vasculogenic Neurogenic Psychogenic Spondylogenic
- Viscerogenic Pain
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
Heart (T1-T5) and Bronchi and lungs (T2-4)
pain referred deep to the sternum, neck shoulders, pectoralis muscles, UE L>R
Esophagus T5-T6
Pharynx, neck, UE’s, sternum
Gastric (T6-T10)
Lower thoracic to abdomen
Gallbladder (T7-T9)
Upper abdomen, lower scapula and thoracolumbar
Pancreas
upper L/S, upper abdomen
Bladder (T11-T12)
Lower abdomen or L/S
Uterus
Lower abdomen or L/S
Kidneys (T10-L1)
Upper L/S, lateral to navel
Viscerogenic Pain has 5 important clinical characteristics
- It is not evoked from all viscera
- It is not always linked to visceral injury
- It is diffuse and poorly localized
- It is referred to other locations
- It may be accompanied with autonomic, reflexes, such as the nausea and vomiting
Vasculogenic Pain
- Vasculogenic pain tends to result from venous congestion or arterial deprivation to the musculoskeletal areas
- 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)
Neurogenic Pain
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
Psychogenic Pain
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.
Spondylogenic Pain
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
Generalized Body Pain
2 conditions that can cause generalized body pain (psychogenic type pains)
Fibromyalgia
Myofacial pain Syndrome
Causes of Cervical Pain
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
Causes of Thoracic Pain
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
Causes of Lumbar Pain
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
Causes of Sciatica
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)
Mechanical LBP–Compression fracture
- ->65 years of age female>male
- -commonly at mid T/S and mid L/S
- -acutely painful, especially with flexion
Mechanical LBP–Vertebral Stenosis
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)
Mechanical LBP–Disc Disease
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
Mechanical LBP Sprain
< 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
Mechanical LBP-Facet Syndrome-Facet Syndrome
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
