Skip to main content
. 2016 Apr 1;113(13):223–234. doi: 10.3238/arztebl.2016.0223

eTable 4. Specific types of low back pain that require further diagnostic evaluation.

Disease Findings Further evaluation Treatment
Disk herniation

  • low back pain and radicular sciatica (worse in leg than in back), sometimes with sensory and/or motor deficits

  • positive nerve-stretching test

  • reflex asymmetry

 Imaging studies:
(DD herniation vs. stenosis vs. tumor)

  • MRI, plain films (CT if MRI is contraindicated)


Neurological/electrophysiological testing:

  • EMG, SSEP, NCS

  • in suspected cauda equina syndrome, examination of bladder and rectal function (post-void residual urine volume, sphincter tone)

 Depending on the clinical findings:
conservative/interventional:

  • analgesic and anti-inflammatory drugs

  • physiotherapy

  • periradicular/epidural injections

surgical:

  • particularly in case of a motor deficit (strength grade 3 or less)

  • sequestrectomy

  • nucleotomy
Spinal canal stenosis / degenerative instability

  • spinal stenosis syndrome, limitation of walking distance (neurogenic intermittent claudication), pain radiating into both legs

  • possibly, sensory and motor deficits

 Abnormally flexed posture of trunk
imaging studies:

  • plain films

  • functional myelography and post-myelographic CT


neurological/electrophysiological testing:

  • ENG, SSEP, EMG

 Depending on the clinical findings:
conservative:

  • pain therapy

  • physiotherapy


interventional:
PDA, sacral block
surgical:

  • decompression

  • decompression and fusion
Axial spondylitis andseronegative spondyloarthropathy Inflammatory back pain syndrome

  • onset before age 45

  • back pain for more than 3 mo.

  • morning stiffness >30°

  • improvement with movement

  • pain at night

  • restriction of lateral bending

  • sacro-iliac joint syndrome

  • enthesitis (heel)

  • insertion tendinitis

 Imaging studies:

  • plain films/MRI (sacro-iliac joint, STIR sequence)

  • inflammatory parameters

  • HLA-B27



rheumatologic consultation

  • analgesic and anti-inflammatory drugs

  • physiotherapy

  • maintenance therapy with rheumatologic drugs if indicated
Deformities

  • scoliosis: idiopathic, structural, neuromyopathic, other

  • idiopathic juvenile kyphosis (Scheuermann’s disease)

  • spondylolisthesis (dysplastic types)

 Clinical features:

  • pelvic tilt

  • shoulder height discrepancy

  • spinal misalignment

  • asymmetry of waist

  • forward bending test

  • hunchback

  • lumbar protrusion

  • hyperkyphosis

  • visible/palpable step in spine

  • sacral kyphosis

  • lumbar spine fixed in extension

 Early detection in children!

Imaging studies:

  • biplanar imaging of the entire spine

  • images on bending

  • MRI (secondary scoliosis, intraspinal anomalies)

  • CT if indicated

 Depending on the patient’s age and on the cause and severity of the deformity:

  • physiotherapy

  • corset

  • surgical correction
Herpes zoster

  • mono- or pluriradicular pain syndrome with sensory deficit (much less often, motor deficit)

  • dermatomal rash, often arising some time after the pain)

 Lumbar puncture and CSF examination:

  • CSF pleocytosis

  • positive CSF serology

  • oral or IV virostatic drugs (aciclovir, brivudine, famciclovir)

  • analgesic drugs: cf. diabetic radiculopathy

  • vaccination of patients at risk
Diabetic radiculopathy

  • painful sensory and motor radiculopathy

  • patient with diabetes mellitus

  • other causes ruled out

  • no rash

  • CSF cell count normal, serology negative

 Pharmacotherapy:

  • metamizole, NSAIDs + TCA/SSNRI or gabapentin/pregabalin; for lancinating pain, carbamazepine/capsaicin 8% ointment; if necessary, high- or low-potency opioids
Neuroborreliosis

  • mono-/pluriradicular pain syndrome with sensory and motor deficits

 Lumbar puncture and CSF examination:

  • CSF pleocytosis, elevated CSF protein

  • intrathecal Borrelia-specific AB

  • IV antibiotic treatment with ceftriaxone and cefotaxime for 14 21 days, along with steroid (prednisone 100mg, decreasing dose)

  • analgesic drugs: cf. diabetic radiculopathy
Spinal ischemia

  • at first, pain in thoracic or lumbar spine, followed by development of spinal cord transection syndrome

  • MRI / spiral CT / angiography

  • inhibition of platelet aggregation

  • analgesic drugs (NSAIDs, high- or low-potency opioids)

  • physiotherapy

AB, antibodies; CT, computerized tomography; CSF, cerebrospinal fluid; DD, differential diagnosis; ENG, electroneurography; EMG, electromyography; MRI, magnetic resonance imaging; NCS, nerve conduction study; NSAID, nonsteroidal anti-inflammatory drug; PDA, peridural anesthesia; SSEP, somatosensory evoked potentials; SSNRI, selective serotonin-norepinephrine reuptake inhibitor; TCA, tricyclic antidepressant