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Mr. Y is a 30-year-old man with low back pain that has lasted for 6 days.

What is the differential diagnosis of low back pain? How would you frame the differential?

Most low back pain is caused by conditions that are troublesome but not progressive or life-threatening. The primary task when evaluating a patient with low back pain is to identify those who have serious causes of back pain that require specific, and sometimes rapid, diagnosis and treatment. In practice, this means distinguishing serious back pain (pain due to a systemic or visceral disease or pain with neurologic symptoms or signs) from nonspecific back pain related to the musculoskeletal structures of the back, called mechanical back pain.

  1. Back pain due to disorders of the musculoskeletal structures

    1. Nonspecific back pain

      1. In general, a specific anatomic diagnosis cannot be made, and there is no definite relationship between anatomic findings and symptoms.

      1. There are no neurologic signs or symptoms.

      1. It is nonprogressive.

      1. Examples include the following:

        1. Lumbar strain and sprain

        1. Degenerative processes of disks and facets

        1. Spondylolisthesis (anterior displacement of a vertebra on the one beneath it)

        1. Spondylolysis (defect in the pars interarticularis of the vertebra)

        1. Scoliosis

    1. Specific back pain

      1. A specific anatomic diagnosis can often be made.

      1. Neurologic signs and symptoms are present.

      1. It can be progressive.

      1. Examples include the following:

        1. Herniated disk

        1. Spinal stenosis

        1. Cauda equina syndrome

  2. Back pain due to systemic disease affecting the spine

    1. Serious, requiring specific and often rapid treatment

      1. Neoplasia

        1. Multiple myeloma, metastatic carcinoma, lymphoma, leukemia

        1. Spinal cord tumors, primary vertebral tumors

      1. Infection

        1. Osteomyelitis

        1. Septic diskitis

        1. Paraspinal abscess

        1. Epidural abscess

    1. Serious, requiring specific treatment but not necessarily immediately

      1. Osteoporotic compression fracture

      1. Inflammatory arthritis

        1. Ankylosing spondylitis

        1. Psoriatic arthritis

        1. Reiter syndrome

        1. Inflammatory bowel disease-associated arthritis

  3. Back pain due to visceral disease is serious and often requires specific and rapid diagnosis and treatment.

    1. Retroperitoneal

      1. Aortic aneurysm

      1. Retroperitoneal adenopathy or mass

    1. Pelvic

      1. Prostatitis

      1. Endometriosis

      1. Pelvic inflammatory disease

    1. Renal

      1. Nephrolithiasis

      1. Pyelonephritis

      1. Perinephric abscess

    1. GI

      1. Pancreatitis

      1. Cholecystitis

      1. Penetrating ulcer

It is essential to understand the clinical neuroanatomy of the lower extremity to properly examine patients with low back pain (Figures 7–1 and 7–2). Figure 7–3 outlines the diagnostic approach to low back pain.

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Mr. Y felt well until 1 week ago, when he helped his girlfriend move into her third floor apartment. Although he felt fine while helping her, the next day he woke up with diffuse pain across his lower back and buttocks. He spent that day lying on the floor, with some improvement. Ibuprofen has helped somewhat. He feels better when he is in bed and had transiently worse pain after doing his usual weight lifting at the gym.

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At this point, what is the leading hypothesis, what are the ...

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