Differential Diagnosis of Thoracic,

Lumbar & Sacrum spine

• A patient visited PT department, during
observation you noted some sway in trunk
posture during walking and right leg length
discrepancy was about 4 cm. No history of
family disease and no other associated
problems.

• What is the possible problem

• A young female student complaint of thoracic
pain , no other visible symptoms. Your
colleague pointed out the heavy weight school
bag of student

• Do you think heavy bag has some importance

• Scoliosis

• Structures
• Non structured

• O’s
 Spine pathologies
• Congenital
• Developmental
• Metabolic
• Degenerative
• Inflammatory
• Infectious
 Anatomy
• Thoracic Vertebrae

• Ribs

• Movements
• Respiratory movement

• Deformities

• Chest deformities
• Scoliosis
• Thoracic khyphosis (Gibbus)
Chest deformity
• Scheuermann's kyphosis 

• It is significantly worse cosmetically and can cause pain.

• It is considered a form of juvenile osteochondrosis of the spine, and is more
commonly called Scheuermann's disease.

• It is found mostly in teenagers and presents a significantly worse deformity than

postural kyphosis.

• A patient suffering from Scheuermann’s khyphosis cannot consciously correct posture

• Whereas in postural khyphosis the vertebrae and disks appear normal, in

Scheuermann’s khyphosis they are irregular, often herniated and wedge shaped
over at least three adjacent levels.

•  Fatigue is a very common symptom, most likely because of the intense muscle work
that has to be put into standing and/or sitting properly. The condition seems to run in
families.
• Lumbar vertebrae

• Weight bearing
• Curve
• Pathology
 Lumbar spine

• 20-25% axial load facet joint

• 70% when degeneration of disk

• Posterior facet direct movement

• Direction controlled by facet

• Closed pack ……… extension
• Open packed ……..midway
• Capsular side flexion….rotation….extension
 Ligaments
• Ligaments

• ALL , PLL , supraspinous , interspinous ,

lig.flavum

• Iliolumber
Why L5-S1 more prone to injury

• More weight

• COG directly through it

• Transition from mobile to fixed so stress

• Angle b/w L5/S1 is greater than other so stress

• Greater level of movement

Load in different posture
 History
• Location of pain:
– Localized or radiating?
• Onset of pain:
– Acute, chronic, insidious?
• Consistency of pain:
– Constant/intermittent?
– Improves/Worsens with
activity?
• Mechanism:
– Flex, ext, rotation, lat. Flex
– Direct blow/trauma
 History

• PMH of injuries/surgery?

• Bowel/bladder symptoms?
– Incontinence or 
frequency
– Immediate referral

• Referral history
When the L5 joins sacrum and become
immobile………

When the first sacral vertebrae attached with L5

and become mobile…..

Lumbrization
Sacrilization
• Slump test is used for ……
• SLR test is used for…….
• Farfan test is used for……
• FABER test is used for…..
• Piriformis syndrome is also called……..

• What is the action of piriformis…..

• When hip at 0 degree
• When hip at 30 degree
• When hip at 90 degree
• In McKenzie concept the Pain of spinal origin can be classified into
followings syndromes
– Posture Syndrome
– Dysfunction Syndrome
– Derangement Syndrome

• In low back assessment you observe that End range stress of adaptively
shortened structures and Mechanical deformation due to prolonged stress
immediately produces pain , this syndrome is called

•  In low back assessment you observe that anatomic disruption and increase
Mechanical deformation due to prolonged stress eventually or immediately
produces pain , this syndrome is called

• In low back assessment you observe that End range stress and Mechanical
deformation due to prolonged stress eventually produces pain , this
syndrome is called
• During treatment session it should be noted that extension
exercises may cause further damage with people with
followings diseases

• During treatment session it should be noted that flexion

exercises may cause further damage with people with
followings diseases

– Disc Prolapsed
– Facet joint dysfunction
– Spondylolysis
– Spondylolisthesis
– Spinal stenosis
A patient complaint of spreading or shooting or
radiating pain towards leg during exercise, it
means

A patient complaint of localizing pain during

exercise, it means

Peripheralize pain
Centralize pain
SLR
 B/L SLR
• Abdominals
• SIJ
• What is the quality of your pain (e.g., shooting, electric, dull,
aching, etc.)?

• This is the question that will definitively tell you if the patient
has radicular pain or axial pain. Radicular pain is sharp,
shooting, and electric.

• Nociceptive pain (axial low back and hip pain) and referred
pain are not sharp, shooting, or electric.

• This is an easy, and very important, distinction to make.

• Patients with Radicular symptoms caused by spinal stenosis will
classically complain of pain aggravated by leaning backward.

• These patients also have improved symptoms with trunk flexion.

• This is often referred to as the “shopping cart sign.” In this sign,
the patient reports improvement of symptoms while shopping
because the patient leans forward while pushing the shopping
cart.

• By contrast, patients with a disc herniation causing Radicular

symptoms will report increased symptoms with trunk flexion.
This is because trunk flexion increases the intra discal pressure.
 Back pain
• Symptom not diagnosis

• Etiology
• Mechanical , inflammatory , developmental , metabolic , Neoplastic etc

• Refereed pain from Abdominal , pelvic etc

Important factor
• Quality of pain
• Age of client
• Systemic complication
• Associated symptoms
Associated sign and symptoms

• Sever chronic back pain and fever referred to physician

• Sustained morning stiffness…..Spondyloarthropathies

• Extra Articular involvement…eyes , skin , GI system…red flag

• Severe and tearing pain with sweating and dizziness originate

from expanding …………abdominal aortic aneurysm

• Burning pain from duodenal ulcer

Classification…..source of back pain
1-Visceral back pain

• More from abdomen &pelvis disease than intrathoracic

disease(neck & shoulder )

• GI , pulmonary , urologic & gynecological …sensory nerve …..pain

• PMH , clinical presentation associated sign and symptoms

• Any person above 45 year , back pain , body temperature

2-Neurogenic back pain

• Sciatica symptom not diagnosis

• Spinal stenosis

• Neurogenic claudication

• Vertebral canal wider when spine flexed

3-Vasculogenic back pain

• Throbbing pain

• Increase with activity…cardiac output increase

• Decrease with rest and stop activity

• Atherosclerosis
• Risk factor….HTN , smoking , age , DM , cholesterol

• Abdominal aortic aneurysm

• Bifurcation of aorta
• Iliac artery
• Femoral artery
4-Spondylogenic back pain

• Bone tenderness and pain on weight bearing

• Associate d symptoms…fever ,weight loss

deformity , night pain

• Osteoporosis
Rheumatic disease

• AS ,Reiter ‘s syndrome , psoriatic arthritis

• Morning pain or stiffness that improve by activity

• Night back pain ,tenderness ,SI involvement

• Fever ,weight loss

• Lab investigation
• Family history
 5-Psychogenic back pain
• Hysterical …anxiety

• Paraplegia with only stocking gloves anesthesia

• Reflexes inconsistent
• Cogwheel motion of muscles

• SLR in sitting or supine

• SLR with planter flexion …..pain
 Primary or secondary cancer
• Lumber more than cervical

• Mets from breast ,lung ,prostate and kidney

• Multiple myeloma is most common primary malignancy involving spine and later
on causing osteoporosis

• Key finding…age older than 50 , recent weight loss, previous malignancy ,

constant pain not relieved by rest or positional change, night pain ,disturb sleep

• MM pain not relieved by supine but compression fracture

• ESR increase , calcium level ,alkaline phosphates increase

• Sympathetic involvement so foot warmer than normal

• Gross muscle weakness and full SLR without history of sciatica
 Thoracic pain

• Pulmonary more than GI and cardiac

Cancer

• More due to length of spine

• Mets from lymph nodes , lungs and breast

Cardiac condition

• Thoracic aortic aneurysm , angina , acute myocardial infarction

, AAA
 Lumbar pain
• Cancer

• Mets
• Prostate cancer
• Testicular cancer

• Cardiac condition

• Renal conditions

• Gastro intestinal condition

• Gynecological condition
• Muscle spasm and tenderness along the vertebrae may be
elicited in the presence of visceral impairment.

• For example spasm on the right side at the 9th and 10th
costal cartilages can be a symptom of gallbladder problems.

• The spleen can cause tenderness and spasm at the level of

T9 through T 11 on the left side.

• The kidneys are more likely to cause tenderness, spasm,

and possible Cutaneous pain or sensitivity at the level of
the 11th and 12th ribs.
• Neurologic signs are produced by conduction block in motor or sensory nerves, but
conduction block does not cause pain.

• Thus, even in a client with back pain and neurologic signs, whatever causes the
neurologic signs is not causing the back pain by the same mechanism.

• Therefore, finding the cause of the neurologic signs does not always identify the
cause of the back pain.

• Conditions such as Radiculitis may cause both pain and neurologic signs but in that
case the pain occurs in the lower limb, not in the back or in the upper extremity, not in
the neck.

• If root inflammation also happens to involve the nerve root sleeve, neck or back pain
might also arise.

• In such a case the individual will have three problems each with a different
mechanism:
1. Neurologic signs due to conduction block,
2. Radicular pain due to nerve-root
3. Inflammation, and neck or back pain due to inflammation of the dura.
Sacrum
Sacroiliac joint

Important Physical event related to sacral injury

• Misstep of curb
• Fall on hip or buttock
• Lifting of object in twisted position
• Childbirth

• SI pain aggravates on sitting and lying on involved side

Inflammatory or infectious

• Ankylosing spondylitis
• Reiter's syndrome
• Psoriatic arthritis
• Inflammatory bowel disease (arthritis
associated with IBD)
Ankylosing Spondylitis

• Chronic , Autoimmune
• 20-40year , Male commonly (3.1)

• Pain better with activity

• Chest expansion less

• Morning stiffness
• Fatigue

• HLA B27
• Bamboo spine
• RA factor
• Reiter disease (Arthritis , Conjunctivitis &
Urethritis)

• Psoriatic arthritis
– Skin and Joints

• IBD
– GIT symptoms
Spondylogenic

• Fracture
– Traumatic
– Insufficiency
– Pathologic

• Osteoporosis (Insufficiency fractures)

• A patient is referred to PT, during examination
you noticed that he has unilateral buttock pain
radiating to posterior thigh above knee. Which
of the following can be the most inappropriate
diagnosis for this patient
• Hamstring injury
• Sacroiliac joint dysfunction
• Disc prolapsed
• Hip pathology
Gynecological
• Pelvic inflammatory disease
• Normal pregnancy

GIT
• Ulcerative colitis
• Irritable bowl syndrome

Cancer
• Primary tumors
• Metastatic lesions (history of cancer)
• Prostate cancer
• Colorectal cancer
• Multiple myeloma
Neuromuscular/Musculoskeletal

• Discogenic disease
• Nerve root compression
• Facet joint pain
• Enthesis (tendon insertion)/ligamentous
sprain
• Degenerative joint disease
• Piriformis syndrome
• Spinal stenosis
• Hip disorder
• A physical therapist is working in an outpatient
clinic, a patient with complaint of low back
pain comes to clinic. He has history of smoking
and inactivity , during observation you noted
that his symymtos get relief from extension
exercises ,what type of pathology you suspect
• Lateral Disc prolapsed
• Facet joint dysfunction
• Spinal stenosis
• All of above
• Coccydynia

• Trauma
• Weight bearing on sitting
• There are different characteristics which are used
for the differentiation of diseases , sometimes
some patient present with morning stiffness and it
improves with activity , that character shows
which of the following condition
• Rheumatic diseases
• Connective tissue diseases
• Spondyloarthropathies
• SLE
• During a party with friends ,an academic
discussion started and one of your friend asked
you that what firstly comes to your mind about
“bamboo spine “ , so what would be your reply
• Rheumatoid arthritis
• Ankylosing spondylitis
• Reiter ‘s syndrome
• TB of spine
• A patient presented with complaint of only
numbness in foot
• A patient presented with radiating pain in the
lower limb and numbness
• A patient presented with numbness, radiating
pain and localized back pain

• What is the difference in pathology of

different structure
• A patient complaint of low back pain with
activity, after stopping activity the pain reduce
when

• Patient stand still for sometime

• Patient sit down

• Central spinal stenosis

• Vascular
• Neural

• Intermittent claudication
• Compression fractures

• Carries spine
• Thanks