Differential diagnosis low

back pain
Disusun oleh : Ahmad Fauza Surya
 Traumatic
• Vertebral fractures
• Ligamentous injury
• Joint strain
• Muscle tears METABOLIC
• Osteoporosis
INFLAMMATORY
• Ankylosing spondylitis
• Rheumatology disorders
Cause of low back pain Acquired
INFECTIVE NEOPLASTIC
• Osteomyelitis – acute and chronic • Metastases
• TB
• Discitis

DEGENERATIVE
• Osteoarthritis
• Intervertebral disc lesions
 General - orthopedic

Onset
• Tiba-tiba  E.c trauma atau lesi pada discus intervertbralis
• Bertahap (gradual)  E.c degenerative disease (OA, OS)

Karaktersitik nyeri :
• Ketika Bergerak nyeri dan ketika istirahat, nyeri hilang  mechanical (HNP, OA, OS)
• Ketika bergerak dan istirahat nyeri terjadi secara terus menerus  susp. Malignansi

Tambahan :
(+) gejala neurologic (retensi urin) ketika bergerak - keterlibatan discus intervertbralis
 TRAUMATIC

ANAMNESIS

Gejala dan tanda: Traumatic

• Nyeri pinggang • Vertebral fractures
Pasien dating (post • Sesak napas
Inspeksi • Ligamentous injury
trauma dengan jelas) • Keterbatasan • Joint strain
bergerakan pada daerah • Muscle tears
vertebra

Pemeriksaan

Lakukan pemeriksaan
neurologis (full)
Normal appearance by X-rays
Vertebral fracture

Anterior wedge-compression
fracture with less than 20 per
cent loss of vertebral body
height.
Wedge compression fracture caused
by slliiped at the top of the staris
Ligamenteous injury and muscle tears
 Ligamenteous injury

Caused by: Physical stress (a combination of flexion and compression)

 INFLAMMATORY
ANAMNESIS
• Commonly : affects young adult males (in spine)
• Intial : sacroiliac joints  later, the whole spine
Ankylosing spondylitis • Main complaint : lumbar stiffness (especially wake
(AS) up in the morning)
• Add complaint : iritis and plantar fasciitis

pain, swelling, reduced range of

Rheumatic disorder motion and stiffness. (fingers, spine,
(RD) neck, etc)

(+) stiff spine

AS In the advanced case, the patient cannot raise the head to see in front
Check : iritis and plantar fascitis.
Examination
Rheumatological disease will also present with problems in other joints (knee,
RD
hip, ankle, fingers)
 INFECTIVE
ANAMNESIS
• PREVIOUS HISTORY :night sweats or cough
• COMPLAINT : malaise, fever, pain, tenderness and
SPINAL TB limitation of movement of the spine

Osteomyelitis • PREVIOUS HISTORY : may also occur in diabetes and the

immunocompromised

Discitis

COMPLAINT : mild backache accompanied by leg pain

osteomyelitis
Fever, malaise, local tenderness (discomfort), and spasm

TB wasting of the paraspinal muscles, spasm and restricted movements.

Examination

discitis discitis there will be reduced movement of the spine

18.25 Spinal tuberculosis – MRI
features Scanning in several
planes shows details that cannot be
seen in plain x-rays.
(a) Sagittal MR images of
advanced tuberculous infection
with abscess formation beneath the
anterior longitudinal ligament.
(b,c) Axial images showing psoas
abscesses communicating across
the front of the spine.
(d) In countries where TB is
endemic, additional active lesions
can be detected by MRI in almost
40 per cent of patients presenting
with ‘local’ lesions.
Spinal tuberculosis

a b
Typical x-ray features are loss
of disc height, irregularity of
the disc ‘space’, end-plate
erosion and reactive sclerosis.
Progressive changes are shown
in (a) and (b). Reactive bone
changes, shown in (c), may end
with fusion at the affected
level. In many cases it is
impossible to tell whether the
infection began in the disc or in
c the adjacent bone.

Note: The infection usually begins in the vertebral endplates

with secondary spread to the disc and adjacent
vertebra
 DEGENERATIVE
ANAMNESIS
• Occur in elderly (50th - >60th )
• PREVIOUS HISTORY :pain made worse on movement and
OA relieved by rest.

Intervetebral disc • Sudden onset of pain radiating down the back of the leg (by
lesion N. sciatica).
• movement, coughing and straining (worsen)
• (+) neurologic symptomps, weakness of a limb, bladder
symptoms

OA There will be limitation of movement of the spine with osteoarthritis

Examination there will be limitation of spine movement, lordosis and neurological symptoms of the
lower limbs
Intervetebral
disc lesion
Full neurologic examination
MRI and discography (a) The lateral T2-weighted MRI shows a small posterior disc bulge
at L4/5 and a larger protrusion at L5/S1. (b) The axial MRI shows the disc prolapse
encroaching on the intervertebral canal and the nerve root on the left side. (c) Discography,
showing normal appearance at the upper level and a degenerate disc with prolapse at the
level below.
 Osteoarthritis in spine

Note : Typical x-ray features are narrowing of the intervertebral

space and anterior ‘osteophytes
 METABOLIC
ANAMNESIS
• A woman at or near the menopause (around 75 years
old)
Osteoporosis • Back pain and increased thoracic kyphosis
• Previous History : low-energy fracture of the distal
radius (Colles’ fracture), the hip or the ankle.

• Conventional • erythrocyte Sedimentation rate (ESR),

radiographs should C-reactive protein (CRP)
be obtained • differential blood count
• Dual energy X-ray • calcium, phosphate
absorptiometry
Diagnostic osteoporosis
(DEXA), is currently
• alkaline Phosphatase (AP)
• serum glutamic-oxaloacetic
considered the best Transaminase (SGOT)
way to assess the risk • creatinine
of a bone fracture
Osteoporosis
 Neoplasma
• Unwell with severe unrelenting pain (particular
ANAMNESIS area that is in spine)
• Previous history have a primary tumour (e.G.
Bronchus, breast, thyroid, prostate or kidney)
• Onset pain : suddenly
Metastasis • May there is pathological fracture (caused by
collapsed vertebrae)

• Palpate along the

spine for
tenderness
Examination Metastasis • Check the chest,
thyroid, breast,
kidney and prostate
for malignancy
 Gynaecological
ANAMNESIS
• The pain is usually low back pain associated
with pelvic discomfort.
• The patient may also complain of
Gynecological dysmenorrhoea, menorrhagia or post-
menopausal bleeding.

Check for pelvic

masses. Carry out
Examination Gynaecological
bimanual
examination.
 Daftar pustaka
• Salter, Bruce R. 1999. Textbook of Disorder and injuris of the
Musculoskeletal System. William & Wilkins.

• A Graham Apley’s, Louis Solomon. 1995. Ortopedi dan Fraktur

Sistem Aplay. Widya Medika; Jakarta