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Back pain and weight loss

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Abbreviations: ABG = Arterial blood gases, ANA = Antinuclear antibodies, BUN = Blood urea nitrogen, CRP = C-reactive protein, CT = Computed tomography, DRA = Dual energy radiographic absorptiometry, DRE = Digital rectal exam, ERCP = Endoscopic retrograde cholangiopancreatography, ESR = Erythrocyte sedimentation rate, HSV = Herpes simplex virus, IVP = Intravenous pyelography, KUB = Kidney, bladder, ureter, LDH = Lactate dehydrogenase, LFT = Liver function test, MRA = Magnetic resonance angiography, MRC = Magnetic resonance cholangiopancreatography, MRI = Magnetic resonance imaging, MRU = Magnetic resonance urography, NSAIDs = Non-steroidal anti-inflammatory drugs, PCR = Polymerase chain reaction, PET - FDG = Positive emission tomography - fluorodeoxyglucose, PET = Positive emission tomography, PID = Pelvic inflammatory disease, PSA = Prostatic specific antigen, PTC = Percutaneous transhepatic cholangiography, RUQ = Right upper quadrant, SPECT = Single-photon emission computed tomography, TFT = Thyroid function test, VZV = Varicella zoster virus

Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Neurological Arachnoiditis[1] Acute Hours Dull aching pain Head, neck and back +/- + +/- +/- +/- +/- +/- +/- +/- - - +/- +/- CSF
  • Elevated protein with normal or low glucose

Culture and sensitivity

Nucleic acid tests

Radiography
  • Thickened nerve roots

CT

  • Narrowing of subarachnoid space
  • Irregular collections of contrast material
  • Thickened nerve roots

MRI

  • Study of choice shows indistinct cord outline
Epidural abscess[2][3] Acute Variable Dull, throbbing pain Locally - +/- +/- +/- +/- +/- +/- +/- +/- - - +/- +/- CBC

ESR

  • Elevated

Culture and sensitivity

  • To identify causative organism

Immunohistochemical staining

MRI
  • Of choice and demonstrates fluid collection

CT

  • Demonstrates fluid collection

Radiography

  • LP carries risk of spread of infection
Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Bone Chronic recurrent focal osteomyelitis[4][5][6] Chronic Years Dull aching pain Local +/- + + - - - +/- - - - - - - CBC

ESR

  • Elevated

CRP

  • Elevated

Procalcitonin

  • Elevated

Culture and sensitivity

  • To identify causative agent
 Radiography
  • Demonstrates endosteal or medullary lesion
  • Sequestration and cavity formation

MRI

CT

  • Articular and periarticular involvement

Ultrasound

  • Soft tissue abnormalities

Nuclear imaging

  • Acute presentation is often seen in children and is associated with gait abnormalities
Discitis[7][8] Chronic Years Dull aching or throbbing Local - + +/- - +/- - +/- +/- +/- - - +/- - CBC

ESR

  • May be elevated

CRP

  • May be elevated

Procalcitonin

  • May be elevated

Culture and sensitivity

  • To identify causative agent
 MRI
  • Narrowing of disk space and low signalling indicates edema

CT

  • Detects lesions earlier than radiography, demonstrates hypodensity of disk and destruction of endplates and calcification of annulus

Radiography

  • Disk space narrowing with destruction of endplates and calcification of annulus

Nuclear imaging

  • Focal uptake of gallium-67 and technetium-99m in area of destruction
  • Most likely due to hematogenous spread of organism
Sacroilitis[9][10] Acute or chronic Variable Dull aching or throbbing Hips and legs +/- + +/- - - - +/- +/- +/- - - +/- - CBC

ESR

  • May be elevated

CRP

  • May be elevated

Procalcitonin

  • May be elevated

Culture and sensitivity

  • To identify causative agent
 MRI
  • Narrowing of joint space and low signalling indicates edema

CT

  • Detects lesions earlier than radiography, demonstrates hypodensity of joint space and destruction of articular surface

Radiography

  • Joint space narrowing with destruction of joint space

Nuclear imaging

  • Focal uptake of gallium-67 and technetium-99m in area of destruction
  • Most likely due to hematogenous spread of organism
Vertebral compression fracture[11][12][13] Acute Minutes to hours Sudden, severe, sharp Shoulders, arms, hips and legs +/- - - +/- +/- +/- - +/- +/- - - +/- - CBC

PSA

Urine analysis

  • To detect Bence - Jones protein

Serum protein electrophoresis

ESR

  • May be elevated
 Radiography
  • Decreased vertebral body height

CT

  • Detects more subtle fractures and calcifications

MRI

  • Useful in those with motor weakness and sensory deficits
  • May demonstrate hemorrhage, tumor, or infection

DRA scanning

  • Detects low bone density

PET scanning

  • To distinguish benign from malignant causes of compression
  • Presents as a midline back pain
Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Referred pain Cholelithiasis[14][15] Acute or subacute Minutes or hours Sharp Tip of right shoulder - +/- +/- - + - +/- - - - - - - CBC

LFT

Amylase and lipase

  • Elevated
 Radiography
  • Radio-opaque stones may be present

CT

MRI

Ultrasound

  • May demonstrate gallbladder wall thickening (>5 mm) and gallbladder fluid and distention
  • Gallstones may appear as echogenic foci that cast an acoustic shadow

Scintigraphy

  • May detect cystic duct obstruction

ERCP

  • Stones are seen as a filling defect and can be removed simultaneously

PTC

  • Similar to ERCP
  • Used when ERCP is not feasible
  • May be completely asymptomatic
Pancreatitis[16][17][18] Acute or chronic Variable Severe, sharp or dull aching Abdomen - +/- +/- - + +/- +/- - - - - - - Amylase and lipase
  • Elevated

LFT

CBC

Serum electrolytes

BUN and creatinine

  • May be elevated

Triglycerides

  • Usually elevated, however, falsely lowered during acute attack
 KUB radiography
  • May demonstrate free air within abdomen, indicating a perforated viscus

Ultrasound

  • Used to visualize the pancreas and biliary tree
  • May detect microlithiasis and periampullary lesions

CT

MRC

  • May demonstrate a blockage within the biliary ducts

ERCP

  • May remove a blockage, however, can in fact cause pancreatitis
  • Usually caused by binge drinking or long standing gallstones that block the ampulla of Vater
  • Vomiting is a common manifestation
Pneumonia[19][20][21] Acute or chronic Variable Variable Chest, back and abdomen - + + +/- +/- +/- +/- - - - - - - CBC

Blood culture

  • To identify causative organism or rule out other organisms such as MRSA
 Radiography
  • Plain x-ray shows multiple patches in the lung fields

CT

  • Used to distinguish pneumonia from non-pneumonias
  • Hospital-acquired pneumonia is common
Rheumatoid arthritis[22][23][24] Chronic Years Severe, aching Variable + - - - - - +/- - - - - - - ESR and CRP
  • Elevated

CBC

Rheumatoid factor

  • May be positive

ANA

  • May be positive

Anti−cyclic citrullinated peptide (anti-CCP) and anti−mutated citrullinated vimentin (anti-MCV)

Radiography
  • Osteopenia is noted
  • Metacarpal bone erosion
  • Narrow joint space without osteophytes

MRI

  • Pannus formation may be noted

Ultrasound

  • Effusion of joint may be seen
  • Symmetric polyarthritis
  • Morning stiffness with improvement throughout the day
  • Deformities of the hand are common
Waterhouse-Friderichsen syndrome[25][26] Acute Minutes to hours Sudden, severe, sharp Back and/or flanks - + +/- +/- +/- +/- +/- - - - - - - CBC

Serum electrolytes

Blood urea nitrogen

  • Elevated

Creatinine

  • Elevated

Plasma glucose 

Serum cortisol

  • Decreased

Plasma ACTH

  • Elevated
 CT
  • Shows adrenal enlargement or adrenal aymmetry
  • Short cosyntropin (Cortrosyn) stimulation test confirms the diagnosis
Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Tumors Ewing's sarcoma[27][28][29] Chronic Months to years Dull aching Variable +/- +/- +/- - - - + - - - - - -

Tests are used to rule out other pathologies; CBC

Blood cultures

  • May be positive for various organisms

ESR and CRP

  • May be elevated

LDH

  • May be elevated

Cytogenetic studies

  • May be positive for t(11;22) translocation

Immunohistochemical markers

  • May be positive for MIC2 antigen (CD99)
 Radiography
  • Periosteal reaction "onion skin"
  • Cortical thinning
  • Mottling

MRI

  • Skip lesions
  • Edema
  • Metastasis

PET - FDG

  • To identify metastatic disease
Leukemia[30][31][32][33] Acute or chronic Weeks to years Aching Variable - +/- +/- - - - + - - - - - - CBC

Coagulation study

Peripheral blood smear

  • May demonstrate blasts, ppschistocyte]]s, auer rods, and mature lymphocytosis

Blood chemistry profile

Blood culture

  • To rule out infection
  • Typically no routine imaging studies, cytogenetic and flow cytometries aid diagnosis
  • Acute and chronic, lymphocytic and myeloid diagnoses are based on the presence and type of blast or mature cell
Lymphoma[34][35][36][37] Chronic Months to years Aching Variable - +/- +/- - - - + - - - - - - Typically no specific lab findings, however, the following routine tests are performed;
  • CBC
  • Serum chemistry studies, including LDH
  • Serum beta2-microglobulin level
  • HIV serology
 Radiography
  • May demonstrate hilar or mediastinal adenopathy
  • Pleural or pericardial effusion
  • Parenchymal involvement
  • Bulky mediastinal mass

CT

  • May demonstrate enlarged lymph nodes
  • Hepatosplenomegaly
  • Filling defects in visceral organs

Bone scan

Gallium scan

  • May show increased uptake

MRI

  • Signal intensity changes are noted in those with bone marrow or muscular involvement

PET - FDG

  • To distinguish between viable, active tumors and necrosis
  • To detect early recurrence

Ultrasound

  • Useful if primary lesion is in testis
Prostate cancer[38][39] Chronic Months to years Severe, sharp Lower abdomen, hips, groin and legs - +/- +/- - - - +/- - - - - +/- - PSA
  • Detection is helpful in diagnosis, usually > 10 ng/ml

Acid and alkaline phosphatase

  • Useful in detecting metastasis

Serurm creatinine and LFT

  • Useful in detecting metasstasis

Urine analysis

Ultrasound
  • Transrectal biopsy transrectal ultrasound may demonstrate hypoechoicity

MRI

  • May be used to guide biopsy
  • PSA and DRE are gold standard for screening
Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Miscellaneous Depression[40][41][41] Chronic Months to years Severe to mild aching Variable +/- - - +/- +/- +/- +/- - - - - - - CT and MRI

PET

  • Allows for study of ligand-receptor binding

SPECT

  • May demonstrate regional blood flow deficits in the left anterofrontal and temporal regions
  • Must assess suicidal ideation
Herpes zoster[42][43][44] Acute or chronic Variable Severe, stabbing, electric-like Dermatomal - +/- +/- +/- +/- +/- +/- - +/- - - - - Tzanck smear
  • May demonstrate multinucleated giant cells

Direct fluorescent antibody test and/or PCR

  • Allows for differentiation between HSV and VZV
  • Typically no routine imaging

MRI

Lumbar puncture and cerebrospinal fluid analysis








References[edit | edit source]

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