Back pain and weight loss

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

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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

* May be due to TB or Meningitis

Nucleic acid tests

* Helpful in tuberculous meningitis

| Radiography

* Thickened nerve roots

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

MRI

* Study of choice shows indistinct cord outline

* Usually caused by meningitis or TB

Epidural abscess[2][3] | Acute  | Variable  | Dull, throbbing pain  | Locally  | \-  | +/-  | +/-  | +/-  | +/-  | +/-  | +/-  | +/-  | +/-  | \-  | \-  | +/-  | +/-  | CBC

* May show leukocytosis, left shift, thrombocytopenia, and anemia

ESR

* Elevated

Culture and sensitivity

* To identify causative organism

Immunohistochemical staining

* Includes gram stain, special stains for fungi and mycobacteria, also consider brucella

| MRI

* Of choice and demonstrates fluid collection

* Demonstrates fluid collection

Radiography

* Demonstrates osteomyelitis or vertebral collapse

* 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

* Leukocytosis and left shift

ESR

* Elevated

CRP

* Elevated

Procalcitonin

* Elevated

Culture and sensitivity

* To identify causative agent

| Radiography

* Demonstrates endosteal or medullary lesion
* Sequestration and cavity formation

MRI

* Bone marrow abnormalities and lytic changes

* Articular and periarticular involvement

Ultrasound

* Soft tissue abnormalities

Nuclear imaging

* Loss of bone density

* Acute presentation is often seen in children and is associated with gait abnormalities

Discitis[7][8] | Chronic  | Years  | Dull aching or throbbing  | Local  | \-  | \+  | +/-  | \-  | +/-  | \-  | +/-  | +/-  | +/-  | \-  | \-  | +/-  | \-  | CBC

* May demonstrate leukocytosis

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

* 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

* May demonstrate leukocytosis

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

* 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

* Decreased hematocrit and anemia

PSA

* To rule out prostate cancer

Urine analysis

* To detect Bence - Jones protein

Serum protein electrophoresis

* M spike is seen with multiple myeloma

ESR

* May be elevated

| Radiography

* Decreased vertebral body height

* 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

* Demonstrates polymorphnuclear leukocytosis

LFT

* Elevated alanine aminotransferase and aspartate aminotransferases
* Elevated conjugated bilirubin

Amylase and lipase

* Elevated

| Radiography

* Radio-opaque stones may be present

* May indicate presence of gallstones in the distal common bile duct

MRI

*     * May indicate presence of gallstones in the distal common bile duct

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

* Elevated alkaline phosphatase, total bilirubin, aspartate aminotransferase, and alanine aminotransferase

CBC

* May demonstrate leukocytosis

Serum electrolytes

* May indicate hypo or hypercalcemia

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

* Pancreas may appear enlarged

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

* Leukocytosis is often demonstrated however, white blood cell count may be normal

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

* 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

* May indicate anemia

Rheumatoid factor

* May be positive

ANA

* May be positive

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

* Are specific to rheumatoid arthritis

| 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

* May show decreased hemotocrit, leukocytosis and rarely, eosinophilia

Serum electrolytes

* Hyponatremia
* Hyperkalemia
* Hypercalcemia

Blood urea nitrogen

* Elevated

Creatinine

* Elevated

Plasma glucose

* Hypoglycemia

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

* May indicate anemia

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

* Mature or immature leukocytosis

Coagulation study

* May demonstrate elevatedprothrombin time, decreasing fibrinogen level, and presence of fibrin split products

Peripheral blood smear

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

Blood chemistry profile

* May demonstrate tumor lysis syndrome through elevated LDH and uric acid

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

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

Bone scan

* Useful in those with elevated alkaline phosphatase

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

* Hodgkin's lymphoma is usually focal and characterized by Reed-sternberg cells
* Non - hodgkin's lymphoma tends to be multifocal
* Biopsy provides ultimate diagnosis

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

* May detect hematuria or infection

| 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  | +/-  | \-  | \-  | +/-  | +/-  | +/-  | +/-  | \-  | \-  | \-  | \-  | \-  | \-  |

* Typically no specific lab findings
* Lab testing is used to diagnose organic causes and include;
* CBC
* TFT
* Vitamin B-12 detection
* Rapid plasma reagin
* HIV testing
* Electrolytes, especially calcium, phosphate, and magnesium levels
* BUN and creatinine
* Blood alcohol level
* LFTs
* Blood and urine toxicology screen
* ABG
* Dexamethasone suppression test
* Cosyntropin stimulation test

| CT and MRI

* To rule out organic brain syndrome or hypopituitarism

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

* Used to exclude myelopathy or encephalopathy

Lumbar puncture and cerebrospinal fluid analysis

* In cases of suspected meningitis, increased protein and pleocytosis will be noted

## References

[edit | edit source]

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2. ↑ Nathoo N, Nadvi SS, van Dellen JR (April 1999). "Cranial extradural empyema in the era of computed tomography: a review of 82 cases". Neurosurgery. 44 (4): 748–53, discussion 753–4. PMID 10201299.
3. ↑ Heran NS, Steinbok P, Cochrane DD (October 2003). "Conservative neurosurgical management of intracranial epidural abscesses in children". Neurosurgery. 53 (4): 893–7, discussion 897–8. PMID 14519222.
4. ↑ Lew DP, Waldvogel FA (2004). "Osteomyelitis". Lancet. 364 (9431): 369–79. doi:10.1016/S0140-6736(04)16727-5. PMID 15276398.
5. ↑ Mader JT, Shirtliff M, Calhoun JH (December 1997). "Staging and staging application in osteomyelitis". Clin. Infect. Dis. 25 (6): 1303–9. PMID 9431368.
6. ↑ Lew DP, Waldvogel FA (April 1997). "Osteomyelitis". N. Engl. J. Med. 336 (14): 999–1007. doi:10.1056/NEJM199704033361406. PMID 9077380.
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8. ↑ Gupta A, Kowalski TJ, Osmon DR, Enzler M, Steckelberg JM, Huddleston PM, Nassr A, Mandrekar JM, Berbari EF (December 2014). "Long-term outcome of pyogenic vertebral osteomyelitis: a cohort study of 260 patients". Open Forum Infect Dis. 1 (3): ofu107. doi:10.1093/ofid/ofu107. PMC 4324221. PMID 25734175.
9. ↑ Foley BS, Buschbacher RM (December 2006). "Sacroiliac joint pain: anatomy, biomechanics, diagnosis, and treatment". Am J Phys Med Rehabil. 85 (12): 997–1006. doi:10.1097/01.phm.0000247633.68694.c1. PMID 17117004.
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30. ↑ Clarke RT, Van den Bruel A, Bankhead C, Mitchell CD, Phillips B, Thompson MJ (October 2016). "Clinical presentation of childhood leukaemia: a systematic review and meta-analysis". Arch. Dis. Child. 101 (10): 894–901. doi:10.1136/archdischild-2016-311251. PMID 27647842.
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36. ↑ Cozen W, Katz J, Mack TM (1992). "Risk patterns of Hodgkin's disease in Los Angeles vary by cell type". Cancer Epidemiol. Biomarkers Prev. 1 (4): 261–8. PMID 1303125.
37. ↑ Bazzeh F, Rihani R, Howard S, Sultan I (December 2010). "Comparing adult and pediatric Hodgkin lymphoma in the Surveillance, Epidemiology and End Results Program, 1988-2005: an analysis of 21 734 cases". Leuk. Lymphoma. 51 (12): 2198–207. doi:10.3109/10428194.2010.525724. PMID 21054151.
38. ↑ Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX (June 2005). "Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage". Clin Transl Oncol. 7 (5): 189–97. PMID 15960930.
39. ↑ Crawford ED, Schutz MJ, Clejan S, Drago J, Resnick MI, Chodak GW, Gomella LG, Austenfeld M, Stone NN, Miles BJ (1992). "The effect of digital rectal examination on prostate-specific antigen levels". JAMA. 267 (16): 2227–8. PMID 1372943.
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