Lumbar Disc Herniation

Differential Diagnosis

Clinical Categories of Low Back Pain AHCPR

Potentially Serious Spinal Conditions Spinal tumor Infection fracture cauda equina syndrome Sciatica nerve root compromise Nonspecific Back Symptoms *AHCPR: Agency for Health Care Policy and Research

Clinical Categories of Low Back Pain CAMPBELLS

1.

Extrinsic lesions
Urogenital system, gastrointestinal system, vascular system, endocrine system, nervous system not localized to the spine, extrinsic musculoskeletal system Infections, tumors, metabolic disturbances, congenital abnormalities, associated diseases of aging

2.

1. 2.

Intrinsic lesions
Spinal musculoskeletal system, local hematopoietic system, local neurologic system Trauma, tumors, infections, diseases of aging, immune diseases

Differential Diagnosis of Low Back Pain

Disease or condition
Back strain disc herniation Osteoarthritis or spinal stenosis Spondylolisthesis Ankylosing spondylitis Infection Malignancy

Patient age (years)

20 to 40 30 to 50 >50 Any age 15 to 40 Any age >50

ATUL T. PATEL, ABNA A. OGLE .Diagnosis and Management of Acute Low Back Pain[J].AAFP, Vol. 61/No. 6 (March 15, 2000).

Differential Diagnosis of Low Back Pain

Disease or condition
Back strain disc herniation Osteoarthritis or spinal stenosis Spondylolisthesis Ankylosing spondylitis Infection Malignancy

Location of pain
Low back, buttock, posterior thigh Low back to lower leg Low back to lower leg; often bilateral Back, posterior thigh Sacroiliac joints, lumbar spine Lumbar spine, sacrum Affected bone(s)

ATUL T. PATEL, ABNA A. OGLE .Diagnosis and Management of Acute Low Back Pain[J].AAFP, Vol. 61/No. 6 (March 15, 2000).

Differential Diagnosis of Low Back Pain

Disease or condition Quality of pain
Back strain disc herniation Osteoarthritis or spinal stenosis Spondylolisthesis Ankylosing spondylitis Infection Malignancy Ache, spasm Sharp, shooting or burning pain, paresthesia in leg Ache, shooting pain, "pins and needles" sensation Ache Ache Sharp pain, ache Dull ache, throbbing pain; slowly progressive

ATUL T. PATEL, ABNA A. OGLE .Diagnosis and Management of Acute Low Back Pain[J].AAFP, Vol. 61/No. 6 (March 15, 2000).

Differential Diagnosis of Low Back Pain

Disease or condition
Back strain disc herniation Osteoarthritis or spinal stenosis Spondylolisthesis Ankylosing spondylitis Infection Malignancy

Aggravating or relieving factors

Increased with activity or bending Decreased with standing; increased with bending or sitting Increased with walking, especially up an incline; decreased with sitting Increased with activity or bending Morning stiffness Varies Increased with recumbency or cough

ATUL T. PATEL, ABNA A. OGLE .Diagnosis and Management of Acute Low Back Pain[J].AAFP, Vol. 61/No. 6 (March 15, 2000).

Differential Diagnosis of Low Back Pain

Disease or condition
Back strain disc herniation Osteoarthritis or spinal stenosis

Signs
Local tenderness, limited spinal motion Positive straight leg raise test, weakness, asymmetric reflexes Mild decrease in extension of spine; may have weakness or asymmetric reflexes Exaggeration of the lumbar curve, palpable "step off" (defect between spinous processes), tight hamstrings Decreased back motion, tenderness over sacroiliac joints Fever, percussive tenderness; may have neurologic abnormalities or decreased motion May have localized tenderness, neurologic signs or fever

Spondylolisthesis

Ankylosing spondylitis Infection

Malignancy

Diagnostic Evaluation of Low Back Pain

FIGURE. Algorithm for the diagnostic evaluation of patients with low back pain. Patients are evaluated according to signs and symptoms or back pain only, sciatica, or possible stenosis. (CT = computed tomography; ESR = erythrocyte sedimentation rate; IV = intravenous; MRI = magnetic resonance imaging)
Adapted with permission from Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 2002;137:593