Differential Diagnosis of Low Back Pain

Elizabeth Huntoon, MD,* and Marc Huntoon, MD†

Low back pain is a symptom affecting millions of adults annually. The etiology of low back
pain may be difficult to determine at times because of the number of diverse anatomic
structures located in or near the low back region. These structures may be causing direct
or referred pain patterns. An accurate diagnosis is essential for both acute and chronic low
back pain conditions. The discussion in this article is extensive but not all-inclusive, and the
clinician should consult other sources for more detailed description of the less common
differential diagnoses.
Semin Pain Med 2:138-144 © 2004 Elsevier Inc. All rights reserved.

KEYWORDS low back pain, differential diagnosis, lumbar spine, pathology

L ow back pain (LBP) is an extremely common symptom

affecting millions of people each year and accounts for a
significant number of physician visits in both primary care
and specialty pain centers across the world. In the United
States, an estimated 90% of adults experience back pain at
some time in their life.1-3 A growing body of literature sug-
gests that in such cases, psychosocial factors as well as spe-
cific behavioral factors related to fear and avoidance may be
of importance.4-6
The structural complexities of the back as well as the
possibility of referred pain from other areas often make
precise localization of pain generators difficult. Pain gen-
erators may include the vertebral column, surrounding
muscles, tendons, ligaments and fascia, or the neural
structures. Fortunately, acute LBP usually is benign in
nature, transient and self-limiting,7 rarely requiring radio-
graphs or other imaging studies.8 A comprehensive history
and physical examination can identify the small percent-
age of patients with serious conditions that require further
investigation. These conditions include malignancy, neu-
rologic deficits, infection, and rheumatologic diseases/dis-
orders.
Table 1 identifies a nonexhaustive list of findings in the
history and physical examination that should raise suspicion
for more serious cases of low back pain, prompting the clini-
*Department of Physical Medicine and Rehabilitation, Mayo Clinic, Roch-
ester, MN.
†Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic,
Rochester, MN.
Address reprint requests to Marc Huntoon, MD, Department of Anesthesi-
ology, Division of Pain Medicine, Mayo Clinic, Rochester, MN, 200 First
Street, SW, Rochester, MN 55905. E-mail: huntoon.marc@mayo.edu
cian to investigate more thoroughly. Early intervention may
ultimately reduce resource utilization and costs.
Although this article focuses on the more common disor-
ders that cause LBP, one should consider a broad differential
diagnosis at presentation to avoid missing less frequent
sources of symptoms. Patients who do not improve within 3
to 6 weeks of the acute event should be reexamined with
consideration for further testing to rule out systemic or rheu-
matic disorders and to clarify the anatomic cause.
Lumbosacral Radiculopathies
Lumbosacral (LS) radiculopathies are commonly caused by
disc herniations. The term herniation describes displacement
of the nucleus, cartilage or annular material beyond the nor-
mal intervertebral disc space. It may be further categorized
into protrusions, extrusions, or sequestration.9,10 The low
back pain associated with LS radiculopathies is usually ac-
companied by unilateral lower extremity pain and paresthe-
sias. Often called “sciatica,” it is most commonly caused by an
irritation of the lower lumbar nerve roots as a result of me-
chanical compression and/or chemical irritation by sub-
stances released from the nucleus pulposus. Other sources of
lumbar radiculopathy include degenerative bone processes,
such as spurring or osteophytes, neoplastic processes, vascu-
lar malformations, or metabolic disorders, such as diabetes.11
The presence of disc herniation does not directly correlate
with pain, as many individuals will have a disc herniation as
an incidental finding when asymptomatic.12,13 Disc hernia-
tions can be unilateral, bilateral or centrally located. The
onset of pain or paresthesias is typically abrupt and often
reported as more severe in the leg versus the low back region.
The symptoms may radiate from the low back or buttock

138 1537-5897/04/$-see front matter © 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.spmd.2004.08.003
Differential diagnosis of low back pain
Table 1 “Red Flags” for Low Back Pain
History of trauma
Bowel or bladder incontinence or retention
History of prior cancer
Unexplained weight loss
History of intravenous drug use
Systemic illness or infection
Low back pain with fever
Constant progressive pain at night
Prolonged systemic steroid use
Advanced age
Saddle anesthesia
region to the anterior thigh, posterior thigh, or the postero-
lateral distal leg, depending on the level involved. Rarely
there is bowel and bladder incontinence or urinary retention.
The patient may have increased pain or paresthesias with
cough or sneeze.
Physical Examination Findings
The clinician may find muscle spasm in the lumbar paraspi-
nal region along with truncal shift to one side. The patient
may exhibit decreased truncal range of motion, a positive
straight leg raising test (SLR), and crossed SLR (positive sci-
atic pain on the affected side induced by contralateral hip
flexion). One should not confuse hamstring tightness with
neural tension pain. With passive movement of the leg, the
seated patient may lean backwards with the leg elevated (pos-
itive flip sign). Upper lumbar nerve root involvement (L2-4)
may produce pain when the patient is placed in the prone
position and the knee flexed (femoral stretch test). Dimin-
ished reflexes, localized motor weakness, or sensory deficit
may be found in specific myotomal or dermatomal distribu-
tions. Table 2 lists typical clinical features seen with LS radic-
ulopathies.
Diagnostic Testing
Magnetic resonance imaging (MRI) is very useful for confirm-
ing the diagnosis as well as to determine the etiology. Elec-
tromyography (EMG) and nerve conduction studies (NCS)
are also useful for confirming the diagnosis as well as level of
involvement and for differentiating a multiple root from a
plexus lesion11 and for assessing the severity of the nerve
injury. The EMG has a high specificity and will rarely be
abnormal in asymptomatic individuals14 but is usually not
performed until at least 3 weeks after the onset of symptoms.
CT myelography is also considered an important tool for
identifying herniated discs.
Lumbar Spinal Stenosis
Spinal stenosis describes a syndrome in which the spinal
cord, cauda equina, and nerve root structures are compro-
mised. The condition generally is idiopathic in nature. De-
generative changes cause encroachment on the central canal,
lateral recess, or foramina by disc bulge, herniation, osseous,
139
or ligamentous hypertrophy.15 Stenosis may be congenital or
more commonly acquired.
Clinical manifestations vary depending on the structures
involved. Neurogenic claudication, unilateral, or bilateral
pain in the low back, buttocks, or lower extremities are com-
mon. Symptoms are produced or worsened with standing or
walking and are reduced with sitting or forward flexion at the
waist.16 There may be numbness, paresthesias, or weakness.
If the condition is severe, the patient may complain of bowel
or bladder incontinence.
Cauda equina syndrome (CES) may present as low back
pain, saddle anesthesia, bilateral sciatica, motor weakness of
the lower extremities, and bladder dysfunction. Along with
the compressive etiology of spinal stenosis, disc herniations
or spinal neoplasms, CES may be caused by noncompressive
conditions, such as ischemic insults, infectious or inflamma-
tory conditions, and spinal arachnoiditis.17
Physical Examination Findings
Neurologic deficits, if present, are mild, unless the condition
is severely compressive or involves the cauda equina. An
absence or decrease is noted in muscle stretch reflexes (MSR)
and SLR may be normal; with lateral recess stenosis, there
may be little or no LBP. Neurological signs may be unmasked
by ambulation with the spine in extension until leg symp-
toms appear. The neurological examination then may reveal
abnormal MSRs, motor or sensory deficits.18
Diagnostic Studies
Plain films may demonstrate posterior osteophytes, facet hy-
pertrophy, or segmental instability but are not sufficiently
sensitive. These changes can be better visualized with CT;9
however, MRI is the best test for radiologic confirmation of
the diagnosis.19
Spondylolisthesis
Spondylolisthesis is a common, painful condition that exists
when there is shifting or slippage of a superior vertebral body
in relation to the one below, usually from failure of the pos-
terior vertebral elements.20 It also can be incidental radio-
graphic finding in asymptomatic person. When symptom-
atic, the amount of low back pain and disability does not
always correlate with the degree of slippage.21,22
Degenerative spondylolisthesis is more common in indi-
viduals over the age of 40. The lamina and pars interarticu-
laris often are intact, but degenerative changes in the facet
joints and intervertebral disks allow slippage to occur. Spon-
dylolisthesis also may occur as a result of bilateral pars inter-
articularis defects (called spondylosis).
Patients may present with dull, achy back pain that may
radiate posteriorly to or below the knees, especially if the
hamstrings are tight. The pain is worse with prolonged stand-
ing, walking, or extension of the spine. Sleeping disturbances
and back stiffness also are commonly reported symptoms.22
140 E. Huntoon and M. Huntoon

Table 2 Clinical Features of Lumbosacral Radiculopathies

Distribution of Paresthesias or Decreased or
Root Pain Sensory Loss Weakness Absent Reflexes
L1 Lower abdomen, Lower abdomen, inguinal Iliopsoas (ⴞ) Hypogastric and
groin, or upper region cremasteric
anterior medial
thigh
L2 Groin, anterior or Anterior and medial thigh Iliopsoas or adductors of
medial thigh thigh or both
L3 Anterior thigh or knee Anterior thigh and knee Quadriceps and thigh Quadriceps
adductors
L4 Can extend below Inner leg Quadriceps and thigh Quadriceps and
knee, often to inner adductors and tibialis medial hamstring
leg or medial anterior (ⴞ)
malleolus
L5 Posterolateral thigh, Outer leg and dorsum of Tibialis anterior, toe Medial hamstring;
lateral calf to foot to great toe extensors, and extensor ankle jerk often
dorsum of foot hallucis longus normal, sometimes
(therefore, impaired decreased but not
heel-walking), absent because
hamstrings, perinei, and only L5 root lesion
tibialis posterior,
gluteus medius
S1 Posterior thigh, calf, Posterior leg, lateral foot, Gastrocnemius-soleus Ankle jerk and lateral
and lateral last two toes and toe flexors hamstring
malleolus (therefore, impaired toe-
walking), hamstring,
gluteus maximus
S2 Posterior thigh and Variable posterior thigh Intrinsic foot muscles (ⴞ), Anal
occasionally calf and saddle area rectal sphincter (ⴞ)
S3 to S4 Buttock and upper Saddle and perineal area, Rectal sphincter Anal
posterior thigh or perianal area
perianal region
Abbreviation: ⴞ, weakness may or may not be present due to variability of innervation.
From Mokri B, Sinaki M: Lumbar disk syndrome, lumbosacral radiculopathies, lumbar spondylosis and stenosis, spondylolisthesis, in Sinaki M
(ed): Basic Clinical Rehabilitation Medicine (ed 2). St Louis, MO, Mosby-Year Book, 1993, pp 503-513. Reprinted by permission of Mayo
Foundation for Medical Education and Research. All rights reserved.

Physical Examination Findings dylolysis or spondylolisthesis. Bone scan imaging, particu-

The clinician may find diminished or increased lumbar lor-
dosis. Lumbosacral tenderness, reduced lateral bending, and
hamstring tightness are common findings.22 The single-leg
hyperextension test may be positive. This useful provocative
test is performed with the patient standing on one leg while
simultaneously extending the low back. The test should pro-
duce pain on the side of the standing leg in a patient with a
symptomatic ipsilateral spondylolytic lesion.20 If instability is
present in the lumbar spine, there may be pain with either
forward flexion or extension. Palpation of the spinous pro-
cess may reveal a “step-off” deformity, which represents a
relative prominence of the lower vertebral body spinous pro-
cess in relation to the one above. Hamstring tightness may
alter the patient’s gait pattern. Tight hamstring muscles also
may cause low back and posterior leg pain with straight leg
raising and should be differentiated from true neural tension.
Diagnostic Studies
Radiographs in AP, lateral, and especially oblique views are
usually adequate to identify degenerative or traumatic spon-
larly SPECT scans, as well as CT scans are useful for confirm-
ing symptomatic pars defects.23 However, no single imaging
technique is capable of visualizing all stages of pars defects,
and a combination of imaging methods are commonly used24
in individuals at high risk.
Facet (Zygapophyseal) Joint Pain
The facet joints are a frequent cause of low back, buttock,
groin and leg pain. They form part of the posterior elements
of the spine, and are true synovial lined joints. Each vertebra
has an inferior (IAP) and superior articular process (SAP),
with the inferior process emanating from the vertebra above
the joint, and the superior articular process from the vertebra
below the joint.
Although radiologic abnormalities are frequent, including
facet hypotrophy, joint space narrowing, sclerosis, and oth-
ers, the appearance of these radiologic markers does not nec-
essarily imply the joint is a pain generator. Clinical signs of
exacerbation of pain with back extension, “loading” of the
facets by extension and ipsilateral rotation, and characteristic
Differential diagnosis of low back pain
pain patterns with absence of radicular findings, morning
stiffness, pain relief with flexion of the spine, and confine-
ment of pain to the low back, hips, buttocks and posterior
legs above the knee are common. As facet joint arthropathy is
a precursor of spinal stenosis, many patients will have a
mixed picture with some element of neural claudication pain
and dynamic radicular features. Precise diagnosis by facet
joint injections and/or medial branch blocks with small vol-
umes of injectate has been advocated by some.25,26
Degenerative Disc Disease and Lumbar
Sprains/Strains
The disc is a nociceptively innervated structure capable of
pain generation. Degenerative disc disease (DDD) is a de-
generative process starting as early as the first or second
decade of life27,28 with a higher prevalence in athletes.29
Lumbar pain that radiates into one or both buttocks is
common, although the association between DDD and LBP
is controversial. The pain is considered “mechanical” in
nature, as it tends to be aggravated by movements such as
bending, twisting, or lifting. Many patients with DDD re-
port decreased discomfort with lumbar extension and
deny neurologic symptoms. Patients may report LB stiff-
ness after sitting.
The disc is one of several structures potentially involved
with low back sprain; tendons, ligaments, muscles, and the
joint capsule also may be injured in a sprain. Sprains occur as
a result of subcatastrophic stretching of fibers, while main-
taining their structural integrity. Acute pain from a sprain can
occur early if the injury is severe or within days with a more
gradual onset. Strains occur by disruption of muscle fibers or
the musculotendinous junction. Acute pain is most intense
24 to 48 hours after the injury and often is associated with
muscle spasm.20 Transitional lumbar vertebrae are not con-
sidered to be associated with LBP, but were associated with
increased risk of degenerative changes in the disc above, in
young healthy men, and decreased risk in the disc below,
among middle-aged male volunteers.30
Physical Examination Findings
The physical examination often reveals a few findings. There
may be generalized or local muscle spasm and tenderness
over the low back and buttocks. The patient may exhibit
signs of stiffness on arising from the seated position. Neuro-
logical examination is normal.
Diagnostic Studies
While not necessary,8 AP and lateral radiographs in patients
suspected as having DDD may show disc space narrowing,
anterior osteophytes, and other degenerative changes. There
may be small amounts of gas within the disc that can be
visualized on plain films as well.9 MRI shows moderately
diminished T2 signal within the disc. Sprains and strains
usually are not evaluated with diagnostic studies.
141
Vertebral
Compression Fractures
Vertebral compression fractures are a common cause of LBP,
especially in the elderly. Relevant historical details include
the age of the patient and history of steroid use or osteopo-
rosis. History of trama is helpful but not necessary, as many
elderly patients may experience fragility fractures with little
or no trauma. Benign osteoporotic compression fractures
may be asymptomatic.31
Physical Examination Findings
Kyphosis in the upper back may be evident as a result of
anterior wedge compression fractures in the thoracic spine;
point tenderness is common in early fractures and often is
associated with muscle spasm. The neurologic examination is
normal unless the fracture impinges on the neural elements.
Diagnostic Studies
Radiographs with a lateral view and CT are helpful for assess-
ing vertebral body height but are of little benefit in the ab-
sence of gross destruction. MRI is used to confirm the degree
of compression and to assess for neural compromise as well
as to classify vertebral compression fractures as benign or
malignant.9 Bone scanning also is useful to determine or con-
firm subtle changes or to assess the chronicity of the fracture.
Ankylosing Spondylitis
Ankylosing spondylitis (AS) is one of the seronegative rheu-
matic spondyloarthropathies that affects both skeletal and
extraskeletal tissues.32 It involves inflammation of the enthe-
sis and synovium. There is a genetic association with the
HLA-B27 histocompatability antigen found in over 80% of
AS patients.32 Sacroiliitis is usually the first manifestation,
presenting as unilateral or bilateral LBP of insidious onset.33
The patient may complain of progressive morning stiffness
and worsening posture or decreased truncal range of motion.
There may be improvement in symptoms with exercise.
Physical Examination Findings
Decreased spine mobility as measured by fingertip-to-floor
distance, occiput-to-wall distance, and chest expansion mea-
surements.34 Gaenslen’s test may be positive. This test is per-
formed with the patient supine and the test leg extended over
the edge of the table. The nontested leg is held by the patient
with the knee flexed. Pain in the SI joint indicates a positive
test. Neurological testing is normal. Tendon and ligament
attachment sites may be painful and swollen.
Diagnostic Studies
Standard AP and lateral radiographs of the spine reveal sac-
roiliitis with bony erosions, sclerosis leading to subsequent
fusion of the SI joint. There is ossification of the spinal liga-
ments with eventual ankylosis, described by some as a “bam-
boo spine.” HLA-B27 may be positive; rheumatoid and ANA
142
are negative. C-reactive protein and erythrocyte sedimenta-
tion rate levels correlate with disease activity.32
Referred Pain
From the Pelvic Girdle
Hip osteoarthritis, trochanteric bursitis, ischial bursitis, sac-
roiliac (SI) dysfunction, piriformis syndrome, and osteitis
condensans ilii are examples of conditions that will refer pain
to the low back. Hip-joint pathology and bursitis of the
greater trochanter (GT) can mimic mechanical or radicular
LBP both in its onset and symptoms.35 Sacroiliac dysfunction
arises with disruption in the mechanics of the SI joint, which
can occur as an aging or degenerative process, through
trauma, or childbirth.36 The cause of GT bursitis often is
idiopathic but may develop as a result of hip osteoarthritis,
tightness of the iliotibial band, or leg length discrepancy.
Ischial tuberosity bursitis is associated with local trauma,
hamstring tightness, or is idiopathic.
Piriformis syndrome is caused by spasm or dysfunction of
the piriformis muscle. A sciatic nerve entrapment may occur
causing sciatica symptoms. The patient may complain of a
dull ache in the low back and mid-buttock region, pain with
walking up stairs, prolonged sitting, or walking. Osteitis con-
densans ilii is a benign cause of LBP, usually found in post-
partum women and is thought to develop as a result of me-
chanical strain placed on the SI joint during pregnancy.
Physical Examination Findings
Limited internal rotation of the hip, antalgic gait, or groin
pain have been identified as being the best predictors of iden-
tifying hip disorders.37 Pain in the groin or hip with single leg
stance, Patrick’s test (also known as FABER’s test— hip flex-
ion, abduction, and external rotation), along with the pres-
ence of a leg length discrepancy are useful for detecting an
underlying hip disorder, SI dysfunction, or GT bursitis. Hip
internal rotation also can cause increased LBP in patients with
piriformis syndrome by placing this muscle on stretch. The
pain often is ameliorated by external rotation of the hip in this
condition. The clinician also may find abductor weakness.
The physical examination for condensans ilii is unreveal-
ing except for localized pain in the low back.38
Diagnostic Studies
Radiographs of the hip or pelvis may reveal the presence of
osteoarthritis or joint pathology at the hip or sacroiliac joint.
If bursitis has been chronic, calcifications may be seen over
the greater trochanter. With osteitis condensans ilii, radio-
graphic images reveal sclerotic changes to the iliac side of the
SI joint with no evidence of erosions.39
Psoas Abscess
and Arachnoiditis
Psoas abscess formation is an uncommon and often over-
looked cause of low back pain, with accurate diagnosis often
difficult to achieve because of atypical symptoms. This diag-
E. Huntoon and M. Huntoon
nosis should be considered in patients with fever of unknown
origin (FUO) and recurrent low back pain who have recently
had spinal interventions, trauma, or systemic infection.40,41
The physical examination often is unrevealing; CRP, leuko-
cytosis, and fever are common. The diagnosis can be con-
firmed with abdominal ultrasound or MRI. Repeat imaging
may be necessary when initial imaging results are not com-
patible with the clinical presentation of psoas abscess.42
Arachnoiditis is another often overlooked cause of LBP.
Patients present with back pain and sometimes lower extrem-
ity pain without a clearly defined clinical pattern.43 There
may be a burning sensation in the low back, legs, ankles, or
feet, unexplained skin rashes or itching, or neurologic defi-
cits.44 Arachnoiditis may develop after contamination of the
spinal cord and membranes with spinal interventions such as
injection, myelograms, or surgery45,46 and may develop
months to years after the initial injury.
This condition is caused by an inflammatory process of the
arachnoid membrane triggering fibrinous exudate, which re-
sult in the nerve roots adhering to themselves or surrounding
structures. The constant flow of cerebrospinal fluid is
thought to interfere with healing because it washes away the
phagocytes and enzymes that prevent the formation of the
scar tissue precipitated by inflammation.44
Diagnostic Studies
Diagnosis of arachnitis commonly is made with MRI or less
commonly with CT.
Discitis and
Vertebral Osteomyelitis
Discitis is an infection occurring in or around the interverte-
bral disk space. Vertebral osteomyelitis refers to an infection
in the vertebral body. Both can occur at any level in the spine
but most commonly occur in the low thoracic and lumbar
regions. These infections are more common in intravenous
drug users, diabetics, immunocompromised patients,47 and
in patients with systemic diseases such as lupus48 and as a
complication of discography,49 spinal injections,50 and intra-
discal electrothermal therapy (IDET).51
The most common infectious agent is Staphylococcus au-
reus, but other organisms, especially Gram-negative bacteria
and fungal agents, have been implicated.52 Common sources
of infection are recent or concurrent urinary tract infection,
pneumonia, and cutaneous infections or dental abscess, al-
though in many cases, the source is not apparent. The infec-
tion is thought to occur through contiguous location, hema-
togenous spread, or lymphatic seeding from remote sites.
Clinical symptoms often are subtle with gradual onset of
LBP and rarely fever or malaise in the adult population. There
can also be an abrupt onset of pain in certain populations,
particularly after recent surgery.52
Physical Examination Findings
Percussion or palpation tenderness over the affected segment
may be evident. SLR may also be positive. Truncal range of
Differential diagnosis of low back pain
motion usually is normal with forward flexion being the pre-
ferred position. Neurological examination is usually normal.
Diagnostic Studies
MRI is the preferred imaging modality for the evaluation of
discitis, providing greater than 90% sensitivity and specificity
in disease detection and critical anatomic information;9 how-
ever, MRI and radiographic abnormalities may lag behind the
clinical syndrome. Radiographic findings include narrowing
of the disc space, destruction of the cortical margins at the
vertebral bodies adjacent to the disc, bone loss, and vertebral
body collapse. Lateral view radiographs are more helpful for
detecting irregularities and erosions of the vertebral end
plates. A bone scan is usually, but not always, positive early in
the infectious process. Gallium scanning is considered an
excellent choice for evaluating resolution of the infection.9
An elevated erythrocyte sedimentation rate, C-reactive pro-
tein, and leukocytosis often are found. Blood cultures are
positive in many, but not all, proven cases.
Diffuse Idiopathic
Skeletal Hyperostosis
Diffuse idiopathic skeletal hyperostosis (DISH), also known
as ankylosing hyperostosis, is an idiopathic ossifying disease
that affects the anterior and lateral spinal ligament attach-
ments to the vertebral bones.53 Nonradicular unilateral or
bilateral back pain is the most common symptom. Patients
may report early morning and evening stiffness. Other
weight-bearing joints may be painful, but spinal pain is the
principal symptom. Patients may report long-standing symp-
toms (years) without significant functional impairment.54
Physical Examination Findings
Physical examination findings are nonspecific but may in-
clude decreased truncal range of motion or muscle spasm.
Diagnostic Studies
Radiographs show confluent, excessive anterior or lateral os-
teophyte formation spanning three or more intervertebral
discs, most commonly in the thoracic and thoracolumbar
spine.
Scoliosis
Degenerative or adult idiopathic scoliosis is not directly
linked to low back pain, but several studies have found lum-
bar or thoracolumbar spinal curvatures ⬎36°55 or right-sided
curvatures56 were associated with increased incidence of LBP.
In patients with scoliosis and degenerative lumbar spinal ste-
nosis, nerve root compression was found most often at the L4
and L5 levels and usually seen on the concave side of the
scoliosis.57 When severe, degenerative scoliosis may cause
neurogenic claudication or radiculopathy, particularly in the
elderly.58
143
Physical Examination Findings
Inspection of the back may reveal pelvic obliquity, one-sided
protrusion of the lumbar paraspinal musculature, or an ob-
vious curvature. Forward flexion of the trunk may produce a
unilateral thoracolumbar “hump.” Palpation often reveals
muscle spasm in the low back. Neurogenic claudication
symptoms may be reported by some patients and differs from
vascular claudication in that symptoms of leg or back pain
usually resolve quickly with sitting or spinal flexion. If radic-
ulopathy is present, the physical examination should detect
appropriate sensory and motor involvement.
Diagnostic Studies
Imaging evaluation of scoliosis is primarily performed with
plain radiographs and MR imaging.59
Cancer Pain
Metastatic disease from breast, prostate, lung, thyroid, and
kidney account for the preponderance of bone metastasis,
and are often painful.60 In many patients, however, pain may
not be present at all or presents as a late symptom. Of the
hematological malignancies, multiple myeloma commonly is
associated with significant bone pain.
Bone turnover as evidenced by osteoclast activation is per-
turbed, with pain mechanisms including periosteal disten-
sion, increased bone pressure, fractures, cytokine or chemi-
cal mediator release, neural or soft tissue inflammation/
distortion, muscle spasm or epidural compression from
ingrowth of vertebral metastasis are common. Secondary
syndromes such as hypercalcemia, epidural spinal cord com-
pression, neurological abnormalities, and bone marrow in-
volvement may signal a malignant cause of pain.61 The pain
character often is a well-defined, aching, constant pain that is
present at unusual times such as resting supine or nocturnal.
The most likely site of spinal skeletal metastasis is thoracic,62
and since nonmalignant thoracic pain is less common, pain
in this location should arouse clinical suspicion.
Diagnosis should be confirmed with MRI or CT myelogra-
phy, as both are sensitive for spinal invasion by metastasis.
Acknowledgments
The authors thank Alan Carlson, Pam Darcy, and Jennifer
Homewood for their assistance in the preparation of the
manuscript.
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