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Masqueraders of Spinal Pain

In addition to the Henschke et al article that I referred to in the last post, I also thought it important to review potential Masqueraders of Spinal Pain.

I reviewed an article by Klineberg et al (2007) that provides examples of medical causes (Masqueraders) of back pain. Something I think as primary contact practitioners we should be aware of .

Examples of medical causes of back pain, and the symptoms often associated with them, as summarised by Klineberg et al (2007) being:

  • Aortic Aneurysm:
    • Back pain that is acute, severe and tearing. It is a true medical emergency.
    • Pain can radiate to the anterior chest.
    • Rest does not relieve it.
    • Palpation over the back and changes in position do not aggravate the pain.
    • Palpation of the abdomen may increase pain.
    • Loss of lower extremity pulses may occur as the dissection progresses.
  • Myocardial Infarction:
    • Back pain is usually mid thoracic and may radiate to the arm or axilla.
    • Typical symptoms being:
      • Anterior chest heaviness
      • Crushing chest pain
      • Diaphoresis (excessive sweating)
      • Sense of impending doom
      • Pain radiating to the shoulder, neck, arm(s).
    • Pain may be unaffected by posture or changes in position.
  • Ectopic Pregnancy:
    • Classic triad of symptoms:
      • Missed menstrual period
      • Vaginal bleeding
      • Abdominal or lower back pain.
    • Patients may also be diaphoretic or in shock
  • Acute Pancreatitis:
    • Can cause thoracolumbar back pain.
    • Often triggered by binge drinking or gallstones.
  • Duodenal Ulcers:
    • Vague abdominal and back pain.
    • Pain often worsens with hunger or with high acid levels in the stomach.
    • Pain often lessens with use of antacids.
  • Urinary Tract Infections:
    • Pain is often across the back and radiates to the groin.
    • Patients often report dysuria, urgency and frequency.
    • If the infection affects the renal system the pain is often more severe and can radiate to the upper back.
    • Fever may also be present.
  • Prostatitis:
    • Characterised by fever and a vague aching pain in the lower back that radiates into the rectum.
  • Gallstones:
    • Patients can experience severe pain in the abdominal or back area when fatty meals are consumed.
    • Pain is colicky (sharp episodic pain occuring at intervals) with periods of improvement and relief.
  • Kidney Stones:
    • Common in middle aged men and women.
    • Interruption of urine flow results in severe pain that may radiate from the thoracolumbar region around to the lower abdomen and groin.
  • Visceral Cancer:
    • Vague low back pain can be the first sign of visceral cancer.
    • Pain is often not relieved by rest and may be most intense at night.
    • Pain progresses regardless of modification of activities and use of medication.

In addition to the above it is also worthwhile being aware of inflammatory disorders that may mimic/masquerade as a joint injury or back pain. Carter (2012) provides the following guidance:

  • Patients with an inflammatory condition may present with one of the four following presentations:
    • A single swollen joint
    • Low back pain and stiffness
    • Multiple swollen/symptomatic joints
    • Joint pain and pain “all over”
  • Inflammatory joint problems are associated with:
    • Pain
    • Swelling
    • Warmth
    • Redness
    • Night pain
    • Prominent morning stiffness (at least 60 mins, often greater than 2 hours)
  • Many inflammatory conditions have other subjective symptoms/history that may raise our index of suspicion in addition to the above mentioned signs. These symptoms/history being:
    • Psoriatic Arthritis:
      • Associated with psoriasis, nail dystrophy, enthesopathy and/or low back pain.
      • Often resembles pattern of joint involvement as per RA but there is no presence of nodulosis, vasculitis or system features of RA.
    • Enteropathic Arthritis:
      • Inflammatory bowel disease (e.g. Ulcerative Colitis, Crohn’s disease, Celiac Disease) may predispose to this.
    • Reactive Arthritis:
      • Autoimmune condition that develops in response to an infection in other areas of the body.
      • May present with additional signs (Reiter’s Syndrome) such as:
        • Urethral discharge and/or eye inflammation (e.g. conjunctivitis).
        • Often rapid in onset.
        • Asymmetric involvement of the large joints of the lower limb together with enthesitis (often at the Achilles).
    • Rheumatoid Arthritis:
      • Usually presents with multiple, symmetrical, small joint involvement.
      • In approximately 15% of cases it presents in a single joint.
      • 80% of patients are Rheumatoid Factor (RhF) positive.
    • Pseudo Gout:
      • Hypothyroidism, hyperparathyroidism and hemochromatosis may cause presentations with gout like symptoms (pseudo gout).
    • Septic Arthritis:
      • Uncommon but may occur in recently aspirated joints.
      • Patient’s often present with fever.
    • Spondyloarthropathies (SA):
      • Refers to inflammatory arthritis of the spine and sacroiliac joints.
      • Applies to conditions such as:
        • Ankylosing spondylitis
        • Reactive Arthritis following genitourinary or gut infections
        • Psoriatic Arthritis
        • Enteropathic Arthritis
      • Patients have an increased likelihood of being positive for HLA B27 but this is not present in all cases.
        • HLA B27 is found in approx 7% of the normal population. The end result being high levels of false positives when testing for its presence. This means that it has low value in screening.
      • Most common in young men below the age of 35.
      • Complain of the typical inflammatory signs outlined above. Often feel better with gentle exercise and/or NSAID’s.
      • If index of suspicion is raise it is important to question regarding history/presence of:
        • Psoriasis.
        • Inflammatory bowel disease.
        • Recent gut or genitourinary infection
        • Iritis
        • Family history of SA
      • Other joint pains:
        • Enthesopathy is often present with SA patients. Most commonly patella tendon, achilles tendon and plantar fascia.
        • Peripheral joints can also be involved. Often asymmetrical, large joints of the lower limb.
      • Look for tenderness over the sacroiliac joints and loss of lumbar lateral flexion.
      • Investigations:
        • ESR or CRP elevations on blood screening (not always elevated though).
        • HLA B27 (see above).
        • X-rays often not assistive in early stages to show changes to the Sacroiliac joints (e.g. sacroiliitis).
        • MRI can detect a significantly higher rate of x-ray negative SIJ changes.

In addition to the above, Sieper et al (2009) have suggested a new criteria for Inflammatory Back Pain in patients with chronic back pain:

  • Five parameters best explained IBP according to the experts:
    • Improvement with exercise
    • Pain at night
    • Insidious onset
    • Age at onset <40 years
    • No improvement with rest
  • If at least four out of these five parameters were fulfilled, the criteria had a sensitivity of 77.0% and specificity of 91.7% in the patients participating in the workshop, and 79.6% and 72.4%, respectively, in the validation cohort.

References:

Carter N. Joint-related symptoms without acute injury. In: Brukner P, Khan K, editors. Clinical sports medicine. Sydney (Australia): McGraw-Hill; 2012. p. 1093-1101.

Klineberg E, Mazanec D, Orr D, Demicco R, Bell G, McLain R. Masquerade: medical causes of back pain. Cleveland Clinic journal of medicine 2007;74(12):905-13.

Sieper J, van der Heijde D, Landewé R, Brandt J, Burgos-Vagas R, Collantes-Estevez E, Dijkmans B, Dougados M, Khan MA, Leirisalo-Repo M, van der Linden S, Maksymowych WP, Mielants H, Olivieri I, Rudwaleit M. New criteria for inflammatory back pain in patients with chronic back pain: a real patient exercise by experts from the Assessment of SpondyloArthritis international Society (ASAS). Ann Rheum Dis. 2009 Jun;68(6):784-8.

Posted in: Clinical Reasoning

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

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