Back Pain, Adult



Back Pain, Adult


Bryson Borg, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Intervertebral Disc Bulge


  • Intervertebral Disc Herniation


  • Facet Arthropathy


  • Intervertebral Disc Anular Tear


  • Stenosis, Acquired Spinal


  • Spondylolysis


  • Spinal Muscle Injury


  • Instability


  • Benign Compression Fracture


  • Schmorl Node


Less Common



  • Osteomyelitis, Pyogenic


  • Osteomyelitis, Granulomatous


  • Metastatic Disease


  • Insufficiency Fracture, Sacral


  • Obstructive Uropathy


Rare but Important



  • Ependymoma, Myxopapillary, Spinal Cord


  • Primary Bone Tumor



    • Multiple Myeloma


    • Osteoid Osteoma/Osteoblastoma


    • Osteosarcoma


    • Chondrosarcoma


  • Aortic Aneurysm


  • Marrow Replacement Processes



    • Sickle Cell


    • Leukemia


    • Thalassemia


    • Mucopolysaccharidoses


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Back pain is a major health and economic problem in the industrialized world


  • Substantial burden to the healthcare system and to the economy as a whole due to lost productivity (disability, absenteeism)


  • Back pain is the most common indication for imaging of the spine


  • Most common causes of back pain are those relating to degenerative changes in the intervertebral discs and facet joints


Helpful Clues for Common Diagnoses



  • Intervertebral Disc Bulge



    • Diffuse (> 50% circumference) extension of the disc beyond its normal margins


  • Intervertebral Disc Herniation



    • Classified by morphology as protrusion, extrusion, or sequestration


  • Facet Arthropathy



    • Joint space narrowing, osteophyte formation


    • Often accompanied by ligamentous hypertrophy


    • May be secondary to altered load bearing in the setting of degenerative disc disease, by which it is almost invariably accompanied


    • “Blocky” facet morphology does not necessarily represent degenerative change


  • Intervertebral Disc Anular Tear



    • Focal T2 hyperintensity in dorsal disc margin, representing disruption of the anulus fibrosus


    • May enhance on post-contrast sequences


    • Relatively frequent finding; majority are asymptomatic


  • Stenosis, Acquired Spinal



    • Narrowing of the spinal canal


    • Multifactorial


    • < 10 mm diameter of the lumbar canal is absolute stenosis


  • Spondylolysis



    • Defect of pars interarticularis, may be unilateral or bilateral


    • Classified into early, progressive, and terminal stages (Morita)


    • Hairline fracture of early stage often difficult to appreciate with CT; can be suggested by MR (hyperintense STIR) or SPECT (tracer avid)


    • Unilateral spondylolysis associated with increased risk of contralateral pars fracture (e.g., terminal spondylolysis on one side with early/symptomatic spondylolysis on the other)


  • Spinal Muscle Injury



    • Muscular strain, with variable degrees of edema/hemorrhage and disruption


    • Best visualized on fat-saturated T2 sequences


  • Instability



    • Greater displacement than normal for a given force through a spinal motion segment resulting in a diminished ability of the vertebral column to protect the spinal cord and nerve roots



    • Multifactorial


    • Dynamic instability: > 3 mm motion between flexion and extension


  • Benign Compression Fracture



    • Due to axial loading injury, especially through osteoporotic bone


    • No or minimal radial expansion of vertebral circumference


    • Horizontal fracture plane; sclerotic band on CT, band-like or triangular T2 hyperintensity on sagittal MR


    • Anterior wedging common; posterior cortex usually intact and neural arch spared


    • Differentiation of benign from pathologic compression fracture is often not straightforward


  • Schmorl Node



    • Herniation of nucleus pulposus into an adjacent vertebral body through an endplate defect


Helpful Clues for Less Common Diagnoses

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Back Pain, Adult

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