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Back Pain and Beyond: Read About Associated Differentials and Evaluation Methods

M3 India Newsdesk Sep 16, 2022

Even though back pain is highly prevalent, it's important to be on the lookout for warning signs and symptoms that point to a more significant underlying pathology or a problem that goes beyond a basic mechanical problem.

Key takeaways

  1. Cauda equina might manifest as urinary, gastrointestinal, or sexual dysfunction.
  2. Evaluate both muscular and nonmuscular reasons.
  3. As an indication of malignant spread or myeloma, back discomfort often persists while laying down.
  4. Thoracic discomfort should be indicative of intra-abdominal or thoracic diseases.
  5. An abnormal stride when the patient enters the room may indicate a severe pathology.
  6. There is minimal evidence supporting the use of X-rays for non-specific back pain.
  7. Severe or increasing neurological deficiency in the lower limbs should be evaluated for prompt referral in the setting of back pain.

Symptoms of back pain

  • Trauma
  • Thoracic pain
  • Abnormal gait
  • Signs and symptoms of cauda equina/cord compression
  • Associated lightheadedness
  • History of osteoporosis
  • History of cancer
  • Immunosuppression
  • Nocturnal pain
  • Systemic upset – unintentional weight loss, fevers and night sweats
  • History of steroid use
  • Age under 20 years of age over 55 years

Caution is advised since the article recommends that suspicion of a spinal fracture or cancer should not be based on the appearance of a single red flag sign alone.


  • Trauma/fracture
  • Inflammatory arthritis
  • Prolapsed disc
  • Muscular/postural problems
  • Referred pain
  • Degenerative
  • Infective causes such as pyelonephritis or discitis
  • Malignancy, such as myeloma or metastatic spread. Ovarian tumours can also present with back pain.
  • Aortic dissection
  • Paget's disease


  1. Cauda equina syndrome and spinal cord compression should not be overlooked. The former is uncommon but, if ignored, has disastrous repercussions for the sufferer. It might manifest as urinary, gastrointestinal, or sexual issues.
  2. Reduced urinary system feeling, a lack of urge to empty, a weak stream, or even the development of faecal incontinence might occur (caused by loss of sensation of a full rectum). Perianal or saddle anaesthesia or paraesthesia may result in alterations to the sense of touch. In the lower limbs, sensory alterations and weakening might develop, making evaluation essential.
  3. Back discomfort may be a sign of lung, prostate, breast, thyroid, or kidney metastasis or myeloma. Frequently, the pain persists while laying down, causing nighttime discomfort, and is accompanied by thoracic pain (which can also be a sign of other causes like aortic aneurysm).

Investigate individuals who are usually sick and have unexplained fever, night sweats and weight loss, as well as those who are immunocompromised, such as those who are infected with HIV or diabetes, or those who have used long-term steroids.

Patient's age

The patient's age and gender should alert the doctor to other potential reasons, such as ankylosing spondylitis in a young male. Patients with osteoporosis and those who are elderly fracture more readily, even from slight trauma.

When a patient is young (45 years old), has pain that is relieved by mobilisation, and has an insidious start and persistent course, consider ruling out inflammatory causes of pain. Inquire about a family history of inflammatory arthropathy.

Pain location

Thoracic discomfort- The location of discomfort is crucial. Thoracic discomfort should alert the doctor to possible intra-abdominal or thoracic problems (pancreatitis or aortic dissection, gastric, duodenal ulceration or retroperitoneal pathology, for example).

Paraspinal region- Pain in the paraspinal region may be more pathognomonic of renal etiologies, such as pyelonephritis or renal cell carcinoma.

Unilateral leg discomfort- It is also important to determine if there are indications or symptoms of sciatica (or lumbar radiculopathy). This often manifests as unilateral leg discomfort radiating below the knee to the foot or toes (but not always). In these circumstances, leg pain is often considerably more severe than back pain; sometimes, back discomfort is minor or nonexistent.

In-person evaluation

  1. A patient's abnormal stride upon entrance may indicate a significant disease. Examine the back; do not overlook shingles or psoriasis (indicating inflammatory arthritis).
  2. Examine the spine for kyphosis, scoliosis, or the 'question mark' look associated with ankylosing spondylitis.
  3. Consider monitoring the blood pressure in both arms as well as other vital indicators such as pulse and temperature. If clinically required, examine spine mobility and consider the straight leg lift or Schober's test. Consider a slump test to determine if the sciatic nerve is inflamed.
  4. A neurological evaluation of the lower limbs is crucial. Depending on the location of the lesion, tone and reflexes may be enhanced and brisk or nonexistent. Any significant or increasing neurological deficiency in the lower limbs should be evaluated for early referral in the setting of back pain. Evaluate strength (observe for foot drop) and plantar reflexes. Note the location of any sensory alterations.
  5. If cauda equina or cord compression is a possibility, consider assessing perianal sensation and anal tone (reduced or loose) (offer a chaperone).
  6. Consider lumbar radiculopathy if symptoms of nerve root compression are present (neurological disturbances in a nerve root pattern). If you suspect a non-muscular pathology, try evaluating the system you believe is the most likely origin of the pain based on the patient's medical history, such as a gastrointestinal exam — is the aorta pulsating?

Virtual assessment

Take into account the following factors while doing an evaluation of a patient remotely through video.

  1. Keep an eye on the patient's walk. How do they appear?
  2. Is the patient able to expose their back? In such a case, search for rashes.
  3. Instruct the patient to do flexion-extension and lateral flexion.

These distant assessments may aid in the development of a management strategy. However, if you are unable to conduct a successful evaluation, an in-person consultation will be required.

Diagnostic tests

History and physical examination are the cornerstones of evaluating back pain, however, if substantial pathology is suspected, the following tests should be considered :

  • FBC
  • ESR
  • Urine dipstick
  • CRP (raised in malignancy, inflammatory/infective causes but often non-specifically raised so interpret results with caution)
  • Bone profile (abnormal in the malignant spread or Paget's disease)
  • Myeloma screen, including serum paraprotein and urinary Bence jones protein
  • PSA (if there is a risk of prostatic malignancy, but counsel the patient about the false positive & negative rates of the test)
  • Renal ultrasound scan

An X-ray may disclose a fracture or infection, but there is no research to support its effectiveness in treating non-specific back pain. An MRI, if necessary, may more reliably identify spinal cord compression or other significant diseases. MRIs should be used with care since they might show radiological alterations that often do not correspond to symptoms.

Click here to see references


Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.

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