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.