Differential Diagnosis II

Low Back

Red Flags
Fracture
major trauma
minor trauma in osteoporotic patient

Tumor
over 50 or under 20 years of age
Hx of cancer
unexplained weight loss
pain that is worse at night

Red Flags
Infection

fever/chills
recent bacterial infection
IV drug abuse or immune suppression
Cauda Equina
saddle anesthesia
recent bladder dysfunction
severe or progressive neurologic deficits

Spinal Infections
Sites including UTI, indwelling urinary catheters,
skin infections, injection sites for elicit drugs;
one of these found in 40% of patients
Sensitivity of fever is 0.27 for Tb; 0.50 for
pyogenic osteomyelitis; 0.82 for spinal epidural
abscess
Specificity for bacterial infection is 0.98
Sensitivity of spinal percussion tenderness is
0.86 for bacterial infection; specificity is poor

Phases of Degeneration
Dysfunction
Instability
Stabilization

Kirkaldy-Willis Model
Kirkaldy-Willis emphasizes the interrelationship of the three-joint complex: two
facet joints and disc
Proposes three phases of pathologic change:
dysfunction phase
unstable phase
stabilization phase

IVD

Posterior Joints
Synovitis
Hypomobility

Dysfunction

Circumferential
Tears

Continuing
Degeneration

Herniation

Radial Tears

Capsular
laxity

Instability

Internal
Disruption

Lateral Nerve
Entrapment

Disc
Resorption

Subluxation

Enlargement
of
Articular Process

LEGEND: Stable

Stabilization
One Level
Stenosis
Osteophytes
Multi-level
Spondylosis
& stenosis
Unstable

Managing Low Back Pain - Kirkaldy-Willis 2nd Ed

Stabilization

Dysfunctional Phase
Characterized by sprain/strains of facet joints
and accompanying facet syndrome and trigger
points
Early disc injury occurs with no visible
radiographic evidence of degeneration
Manipulation plus trigger point therapy is
most effective treatment for pain and possibly
for prevention

Unstable Phase
Damage in dysfunctional stage predisposes to
further injury leading to loss of support from
facet joint capsules and disc
Conditions seen in this phase include:

unstable facet and SI syndrome

degenerative spondylolisthesis
lateral canal stenosis
disc herniation with or without radiculopathy

Stabilization Phase
The stabilization phase is the bodys attempt
to stabilize the spine through bony
outgrowths
Conditions in the phase include:
fixed lateral canal stenosis
central canal stenosis
other types of bony ankylosis

Dorsal Root Ganglion Compartment

Syndrome
Vascular structure for DRG includes primarily an
internal arterialization with a superficial venous
drainage
This may render the DRG vulnerable to ischemic
consequences of external pressures and/or internal
edematous swelling
A compartment-like syndrome may develop due to
periforaminal degenerative changes or other spaceoccupying effects
Parke WW, Whalen JL. Spine, 27(4), 347-352, 2002

Oswestry Disability Index

10 Functional sections
6 possible answers in each
Range of score is from 0 to 5
Add answer choice scores together and
multiple by 2 to get a percentage of
disability
Less than 5 minutes to fill out; 1 minute to
score

Roland-Morris
24 item survey
Add marked items to together to arrive at a
score
A visual analog scale is often used with the
Roland Morris

Use of X-Ray and Special Studies

Initially x-ray or special studies are recommended
only if there is a red flag or evidence of neurologic
dysfunction
In the absence of red flags, special studies are not
suggested for at least four weeks and:
when surgery is being considered, or
evaluate potentially serious spinal pathology

Electrodiagnostic Testing
EMG does not become positive for 3-4 weeks
post-injury; denervation occurs first
proximally; + findings include hypersensitivity
reactions of fibrillation potentials and positive
sharp waves
Reflex and SSER are abnormal immediately
F response measures motor nerve; single
nerve radiculopathy may not cause an
abnormal F response

Sacral Base
Line
Superior aspect
of S1
Intersects
True
Horizontal
line
Should not
exceed 46o
Low Back Pain - Cox, 6th Ed

Lumbosacral
Angle
Should
intersect
just
posterior to
L5-S1
facets

~8-12o
Low Back Pain - Cox, 6th Ed

Fergusons
Weightbearing Line
Center of L3
body
True Vertical
line
Intersect
anterior 1/3
of S1
Low Back Pain - Cox, 6th Ed

Facet Syndrome
Concerns:
lading of facets with adjusting may increase
compression and pain
difficult modifiable factors such as being overweight,
hyperlordosis, associated degenerative disease
Options for treatment
avoiding loading facets during manipulation
stretch/strengthen to decrease loading
weight loss, avoidance of high-heels, temporary use of
heel lifts

Disc Lesion with Radiculopathy

Concerns
risk of increasing lesion or pain
degree of residual (I.e. is neurologic deficit
permanent)

Options for treatment

non-osseous approach
with side posture load facets into extension and
minimize rotation

Ankylosing Spondylitis
Positive four out of five following screening questions has a
sensitivity of 0.95; specificity of 0.85 in one study
1. Morning stiffness?
2. Improvement with exercise?
3. Problem began slowly?
4. Pain persisted for more than 3 months?
Predictive value of a positive test is low
Reduced chest expansion is highly specific (0.99), however
insensitive (0.09)

Ankylosing Spondylitis
Concerns:
inflammatory arthritide
cardiopulmonary involvement

Options for management:

adjusting okay initially, with progression
caution and decrease in degree of force
daily stretching, mild/moderate exercise
monitor for cardiac involvement

Van Akkerveekens Assessment

Stable segment: AB =
AC

Unstable segment
if
AB < AC
by at least 3 mm

Spine 4(3): 238; 1979

B
C

Van
Akkerveekens
Assessment

Low Back Pain - Cox, 6th Ed

B
C

Regarding Low Back Pain, Facets

and Injections
This study could not identify clinical facet joint
syndromes or predict patients responding better
to this procedure.
The facet joints were not commonly the single or
primary source for low-back pain in the great
majority (greater than 90%) of patients studied.

Ann Rheum Dis. Volume 54(3).March 1995.182-188

Maigne's syndrome
Treatment
Acute
Any technique that will distract the joint
Reduce subluxation
Use ACUTE phase physiotherapy protocol directed at
the ORIGIN of the problem

Chronic
Any technique that will distract the joint
Reduce subluxation
Ergonomic advice and low back stabilization

Managing Low Back Pain - Kirkaldy-Willis 2nd Ed

Myofascial syndromes
Gluteus maximus
Symptoms and signs
Local pain and tenderness in mid buttock region with
focal points within that region
Often associated with an SI syndrome

Gluteus medius
Symptoms and signs
Very focal pain and tenderness in mid gluteus medius
with referred pain down posterior thigh and calf as well
as lateral thigh and leg

Myofascial syndromes
Gluteus minimus
Symptoms and signs
Very focal pain and tenderness in mid gluteus
minimus with referred pain down the anterolateral thigh and leg

Tensor fasciae lata

Symptoms and signs
Focal pain and tenderness in tensor fasciae latae region
with referred pain into the antero-lateral thigh and leg

Myofascial syndromes
Hamstring
Symptoms and signs
Local pain and tenderness over the hamstring
originating from the ischial tuberosity

Piriformis syndrome
Presents as a twisting injury of one leg while
carrying or lifting in an awkward position

Piriformis
Psoas/ Iliacus

Quadratus lumborum
1 = superficial
2 = deep

Quadratus lumborum
deep

TFL

Gluteus minimus

Gluteus minimus

Gluteus maximus

Piriformis syndrome
Symptoms
Local pain and tenderness near the ischial spine
Often deep seated in upper buttock, rectum or vagina
Referred pain down the posterior thigh to the knee
and sometimes ankle and bottom of foot
Pain as patient resists doctors attempts to press
patient's knees together while seated with ankles
together
Spasm or trigger point in the piriformis muscle
Often worse at night and after prolonged sitting

Meralgia paresthetica
Disorder of the lateral femoral cutaneous
nerve from compression near the ASIS
Frequent in diabetics, pregnancy, obesity, or
after pelvic fracture
Symptoms may be emulated by compression
of spinal nerve at the IVF by spinal tumor

Lateral canal stenosis

May occur alone or with a Disc herniation or it may
occur post discectomy
Degenerative changes in the disc and facets
The superior facet moves upward to impinge on the
pedicle above, narrowing of the IVF, especially the
lateral portion

Factors Predicting Longer Recovery

History of more than 4 episodes
Longer than 1 week of symptoms prior to
seeing doctor
Severe pain
Pre-existing structural pathology related to
new injury or condition

Risk Factors for Chronicity

Previous Hx of LBP
Total work loss greater than 12 months
Heavy smoking
Personal problems, depression, stress
Adversarial medicolegal problems
Lower education status
Heavy physical activity in occupation

Risk Factors for Chronicity

Radiating leg pain

Low job satisfaction
Reduced SLR
Signs of nerve root involvement
Reduced trunk strength and endurance
Waddells signs

Waddells Signs
Presence of 3/5 significantly correlated with
disability:
Superficial or nonanatomic tenderness
simulation
distractions
regional disturbances
overreaction

McKenzie Approach
Postural Problem - no pain through
movement testing
Dysfunctional Problem - pain only at endrange of active or passive movement
Internal Derangement - pain felt during
movement pattern
peripheralization of pain
centralization of pain with position change

Lumbar Stenosis Surgical Outcomes

Factors significantly correlated with poorer outcome
included:

female sex
presence of compensation or litigation factors
no relief of symptoms from prior surgical procedures
a diagnostic nerve root block preoperatively
an objective postoperative sensory deficit

Spinal Disord. 1991 Mar. 4(1). P 26-33

Factors significantly correlated with

successful surgical outcome
Best for those with the dynamic type of
stenosis, 96% received leg pain relief
For those with the fixed type, 50% received
leg pain relief
Back pain was not as significantly reduced for
either group

J Neurosurg. 1990 Jan. 72(1)

Abdominal Aneurysm
Concerns:
may be virtually invisible unless outlined by calcification on
radiographs
area is fragile and may be susceptible to mechanical forces
during an adjustment
most large aneurysms progress to rupture
Management:
with older patients always auscultate for bruits
always examine lateral films for direct/indirect signs of
aneurysm
refer for diagnostic US is suspicious (those greater than 4-6
cm are sent to surgery)

Malignant Neoplasms
Accounts for only 1% of LBP episodes
Previous Hx of cancer - specificity = 0.98; sensitivity = 0.31
(only one third of patients have a Hx)
> 50 years old - 80% of patients
Unrelieved by bed rest - sensitivity = >0.90; nonspecfic
No cancer found in group <50, without a Hx of cancer,
unexplained weight loss, or failure of conservative care sensitivity = 100%

Spinal Cord Tumors

Astrocytoma
Ependymoma
Hemangioblastoma
Intradural lipoma

Intramedullary spinal cord metastasis

Astrocytomas
75% in cervical and thoracic areas
20% in distal cord; 5% in the filum
terminale
Occur most frequently in thirties/forties
50% to &0% present with back, neck or
leg pain; 20-30% have spasticity and
stiffness of legs
Survival period is from 1 to 8 years

Ependymoma
Slow-growing, benign tumors arising
from ependymal cells in
central canal (intramedullary)
filum terminale
sacral area (extradural/extraspinal)

Represent 60-70% of spinal cord tumors

60% occur in the conus, filum, or cauda
equina

Hemangioblastoma
Benign tumor composed of dense
network of capillary and sinus channels
Usually intramedullary; may be
intradural/extramedullary involving
posterior roots of cauda equina
Soliatary or multiple; when multiple
associated with von Hippel-Lindau
disease whose patients develop renal
cell carcinoma

Intradural Lipomas
Benign neoplasms composed of fat cells
Three types:
filum terminale
intradural
lipomyelomeningocele

Most common in thoracic spine; males more

commonly affected
The intradural are not commonly a cause of
radicular pain unlike filum terminale lipoma

Intramedullary Spinal Cord Metastasis

Found in only 1-3% of tumor patients

Lung and breast cancer most common
Other non-CNS processes such as
melanoma, leukemia, and lymphoma
may metastasize to the cord
CNS tumors that may involve cord are
glioblastoma, ependymoma, and
medulblastoma

Extramedullary tumors: Meningiomas

Meningiomas account for 25% of

intraspinal tumors
Occur from 20-60; peak in 40;s; female
predominant (4:1)
Predominance at exits of spinal nerves
from dural sleeves
Most common in T-spine, they
compress but do not invade spinal
nerves or cord

Extramedullary Tumors: Neurinoma

Most common extramedullary (29%)
Originate from sensory nerve roots;
usually in C- and T-spine, however, 40%
occur in L-spine
Peak incidence in 5th decade; male
predominant
Generally singular; when multiple
associated with von Rechlinghausens

Cauda Equina Syndromes

Conus lesions - ascending, progressive,
bilateral involvement of sacral nerve rootstumor most common
Characterized by insidious rectal/back/perineal
pain with saddle anesthesia, loss of sphincter
control, urinary retention, or sexual impotence
Motor loss not apparent until later when L5 or
S1 is affected

Central Canal stenosis

Symptoms
Picture is bizarre
Usually presenting with pain in one or both legs
May involve one dermatome in one leg and a
different dermatome in the other
Walking will usually produce leg pain after 3-4
blocks requiring a few minutes rest before
resuming the walk

Central Canal stenosis (continued)

Symptoms
Walking will usually produce leg pain after 3-4
blocks requiring a few minutes rest before
resuming the walk
Sensory changes are common
Perceived muscle weakness and limb coldness
although severe weakness is rare and limb
coldness is not perceived by the examiner

Central Canal stenosis

Signs
Only slight movement limitation with mild pain
Sensory and motor changes may extend over several
dermatomes differing from leg to leg
Motor weakness can follow the same pattern
Pheasant test - lying prone with legs flexed - may increase the
neurological deficit.
Five minutes of walking may also increase motor weakness
when tested
Symptoms of neurogenic claudication (NCIL) are relieved within
15-20 minutes of sitting

Central Canal stenosis

Radiographic
Disc height diminished
Enlarged posterior facets (especially the medial
facet of the motor unit, i.e., the inferior facet
of the superior vertebra)
Osteophytes from bodies (the disc bar)
IVF narrowing
Possible signs of instability with stress views
(flexion / extension)

Central Canal stenosis - Treatment

Acute
Any technique that will distract the joint and open the
Central canal
Home care to include 90/90 positions; sitting is better than
standing; NSAIDS
Use ACUTE phase physiotherapy protocol

Chronic
Same as above replacing PT with Ergonomics and low back
stabilization

Compression Fractures
Long term corticosteroid treatment,
specificity = 0.99
> 70 years old; specificity = 0.96
No history of identifiable trauma;
sensitivity = 0.30
African-American and Mexican-American
have 1/4 as many compression fractures
as Caucasian women

Osteoporosis Compression Fractures

Radiographic signs:
Vertebral compression
fractures in about 40% of
white postmenopausal
women
Thoraco-lumbar region
Heal within 2-3 months
Persistent back pain after
that usually from the
altered mechanics and
fatigue of the trunk
muscles

Radiographic signs:
Gibbous formation with
severe or multiple
compressions
Neurologic complications
are rare; the posterior
vertebral body cortex is
usually spared.
There may be, however,
cord compression from a
large gibbous formation.

OSTEOPOROSIS
Definition: Not clear and varies throughout the
healthcare field. Most agree that it is an
absolute decrease in apparently normal bone.
Osteopenia = less bone tissue than normal;
may be due to osteomalacia or osteoporosis

Etiology
IDIOPATHIC: no discrete cause identifiable.
INVOLUTIONAL:
Type I = postmenopausal (15-20 years post
menopause)
Type II = Senile (usually around 70 years for men
and women)

MANY OTHER DISEASE

PROCESSES MAY RESULT IN
OSTEOPOROSIS

General information
80% of bone volume is cortical but only 30% of bone
surface due to the vastness of the cancellous bone; it
is 1/2 of the compressive strength.
Normal bone 20% tissue water; 10% crystal bound
water; 30% organic material, and 40% mineral.
Normal aging decreases crystal-bound water and
increases mineral.

There is a continual increase in

bone mass

Until age 30, then it declines

As much as 50% mass may be lost in females
(1/3 less in males)
This normal process may be accelerated due to
abnormal rate of decline or insufficient
production initially

Type I (postmenopausal)
Affects trabeculae predominantly
More vertebral fractures than femoral necks
(Women 6:1)

Type II (senile)
Combined loss of cortical and trabecular
become equal
Femoral neck fractures increase (Women still
2:1)

Pathogenesis
Some unknown connections
Oophorectomy, ovarian dysfunction and
premature menopause increase chances for
Type I osteoporosis
Malnutrition, DM, Cushings syndrome,
hyperthyroidism, long-standing corticosteroid
use.

Radiographic signs
Vertebral compression fractures in about 40% of
white postmenopausal women
Thoraco-lumbar region
Heal within 2-3 months
Persistent back pain after that usually from the
altered mechanics and fatigue of the trunk
muscles
Gibbous formation with severe or multiple
compressions

Neurologic complications
Rare
The posterior vertebral cortex is usually
spared.
There may be, however, be cord compression
from a large gibbous formation.

Another pathologic process

should be suspected if:

The posterior aspect of the body is involved

The fracture is above T6

UTI

UTI

UTI

U
T
I

UTI

UTI
E. coli is responsible in 80% of cases where there
is no abnormality or renal calculi
Staph. aureus is common after some type of
instrumentation (e.g. catheterization)
Presence of staph. Aureus = suspicion of bacteremic
infection of the kidney rather than lower UTI

Klebsiella, proteus, chlamydia, gonorrhea, and

herpes simplex may also produce urethritis with
pyuria.

UTI Pathogenesis

Gender and sexual activity

Pregnancy
Obstruction
Neurogenic bladder activity
Vesicoureteral reflux
Bacterial virulence

UTI Pathogenesis
Gender and sexual activity
Males
prostatitis and obstruction due to prostatic hypertrophy

Females
urethral position increases susceptibility during intercourse
diaphragm use is associated with a 2-fold increase in risk

UTI Pathogenesis
Pregnancy
Increased Upper UTI due to

decreased ureteral tone

decreased ureteral peristalsis
temporary incompetence of vesicoureteral valves
bladder catherization post delivery

UTI Pathogenesis
Obstruction
Impediments to the free flow of urine predispose the
region to infection
tumor, prostatic hypertrophy, or stone

Infection can destroy renal tissue quickly

UTI Pathogenesis
Neurogenic bladder activity
interference to nerve supply
spinal cord tumor, tabes, MS, or diabetes

infection may be introduced by catheter or longstanding urine in the bladder

immobilization stimulates demineralization which can
lead to stones and obstruction

UTI Pathogenesis
Vesicoureteral reflux
Usually associated with abnormalities of the tract e.g.
ureterovesical junction that induces reflux

Bacterial virulence
Strains that cause UTI are usually resistant to the
bactericidal action of human serum

UTI
Signs

Upper UTI

Lower UTI

serum antibodies

yes

no

antibody coating of
bacteria (probably not done
in your office)

yes

no

decreased urine concentration

yes

no

yes

no

white cell casts

UTI
Symptoms

cloudy & malodorous

blood
pyuria without casts
tender urethra
fever > 101 F
chills
nausea & vomiting
diarrhea

Upper UTI

no
no
no
no
yes
yes
yes
yes

Lower
UTI

yes
yes
yes
yes
rare
rare
rare
rare

Prostate specific antigen (PSA)

PSA starts out in the fluid that carries sperm.
PSA is a protein normally made in the prostate
gland in ductal cells. These cells make some of
the semen that comes out of the penis during
sexual climax (orgasm). PSA helps to keep the
semen liquid.

Thoughts
Normal" PSA does not mean you are guaranteed free from prostate
cancer.
Higher than normal" PSA does not necessarily mean you do have
anything malignantly wrong with your prostate.
Low level PSA (from 0 - 3.9 nanograms per milliliter of blood) is generally
considered normal
PSA levels higher than 3.9 ng/ml can indicate a problem with the prostate,
including inflammation, infection, enlargement or cancer.
But 20% of prostate cancers develop while PSA levels are in the 'normal'
range.

Some men without any prostate problems show PSA levels higher than
normal.
Only about 1 out of 3 men with elevated PSA levels have cancer.
Some men can be healthy and well despite an elevated PSA.

Three main conditions with elevated PSA

Three conditions in which PSA leaks out of prostate
tissue into the bloodstream and can be measured by
a PSA test.
Prostatitis and Lower Urinary Tract Symptoms (LUTS) can
elevate PSA
BPH (benign hypertrophy or enlargment of the prostate)
can elevate PSA
Prostate cancer (PCa) often elevates PSA -- but not always.
Some of the most aggressive types of prostate cancer do
NOT make or "leak" high levels of PSA.

Benefits of the PSA test

Detecting prostate cancer long before any
symptoms present themselves
Early detection before the cancer has spread
outside the gland makes treating the cancer
easier and offers the only hope for cure
A significant reduction in prostate cancer
deaths

Drawbacks of the PSA test

Approximately 20% of cases, PSA tests show 'normal' PSA
levels in men with early prostate cancer
Does not distinguish between prostate cancer and other
commoner prostate problems like infection (prostatitis) or
benign overgrowth of the prostate (benign prostatic
hypertrophy, or BPH).
2 out of 3 of those with elevated levels of PSA do not have
prostate cancer, so the test may cause undue worry
Men over the age of 75 may not benefit from the test, as
treating prostate cancer in men past age 75 is less likely to
lengthen life span

Events may lead to temporary rise in PSA

Sexual intercourse or any ejaculation within 24 hours before the test. To
be sure, don't ejaculate for 48 hours before a PSA test.
Digital rectal examination causes "a modest increase in total and
percentage of free PSA." Make sure your doctor performs the PSA test
before the digital rectal exam.
Prostate biopsy "can lead to a dramatic increase of PSA in serum and keep
the PSA value high in one week." After biopsy, it takes a month or more for
PSA to return to baseline.
There is no connection has been found to caffeine and tests of strenuous
bike riding (13 hours on a mountain bike) showed no PSA rise at all.