This article is more than 5 years old. Information may no longer be current.
Many dangerous conditions can mimic spinal disease
Nerve and vascular problems in the spine and elsewhere often masquerade as more basic cervical or lumbar disease.
The diagnosis of patients with back pain may be difficult for physicians because many nonspine conditions may masquerade as simple spinal disease. Physicians should watch for a number of red flags when diagnosing certain types of back pain.
Masqueraders discussed by physicians at the North American Spine Society 19th Annual Meeting in Chicago included hip disease, vascular claudication, lumbar radiculopathy and amyotrophic lateral sclerosis. “Low back pain is a masquerader; I think that’s what it is all the time. There are more than 60 disorders which may present with symptoms of low back pain. [Of these], 80% to 90% of all problems are mechanical; nonmechanical disorders [account for] 10% to 20%,” said David Borenstein, MD, of Washington, D.C.
|
Borenstein described several possible diagnoses derived from a presentation of back pain, including vascular claudication and anklyosing spondylitis (AS).
“AS is an inflammatory arthritis that affects the axial spine,” Borenstein said. “It usually starts in the sacroiliac joint and ascends contiguously to involve the cervical spine, but individuals may have varying degrees of involvement.”
Patients with AS often present with low back pain and stiffness that lasts longer than three months. The stiffness improves with exercise but rest does not relieve it, and patients have limited range of spinal motion and decreased chest expansion. Physicians should look for radiographic criteria as well when bilateral sacroiliitis is present, and Borenstein said that these clinical findings along with radiographic criteria provide a relatively clear diagnosis of AS.
Risk of fracture
The presence of AS can increase the risk of fracture, specifically in the thoracic and cervical spine. This is due to inflammation, lowered bone density leading to osteoporosis, and decreased mobility.
“This is a very significant, potentially devastating disease,” Borenstein said. “Luckily we have better therapies for this illness now.” While AS used to be debilitating and sometimes eventually crippling, physicians now have better drugs and other options.
“It’s important to remember that there are nonpharmacologic options including patient education, joint protection and maintenance of function and posture. We tell them that we don’t want them sleeping with pillows,” Borenstein said. Tumor necrosis factors (TNF) can treat this illness too, and have the potential to reverse or halt the inflammatory changes in the spine.
“Identifying these individuals early can make a major effect on their lives, decrease the inflammation they experience and prevent some of the changes that we’ve seen over time in these individuals,” Borenstein said.
Masquerading conditions
Gordon R. Bell, MD, of the Cleveland Clinic, discussed several masquerading conditions including lumbar radiculopathy and hip disease. He stressed that most back pain is mechanical in nature, and different movements and activities induce and relieve the pain. When taking a patient’s history, differentiating between mechanical and other more sinister causes is important.
|
“We’re looking at provocative factors and palliative factors,” Bell said. “We look for exacerbation of symptoms by coughing and sneezing, or by bowel and bladder problems, which can suggest interdiscal pressure. We look for numbness and tingling … and we look for other potential serious things such as night pain or weakness.”
Radicular symptoms can be due to nerve problems in any number of locations, Bell said. Nerves can be compressed or irritated anywhere in the back or distally down the leg by things such as tumors, aneurysms or other less-serious causes.
Hip disease is another problem that often results in low back or buttocks pain. “We know that patients who have hip arthritis commonly present with groin pain,” Bell said.
“[If] a patient presents with groin, anterior thigh or knee pain, one ought to think first of hip disease because it’s fairly easy to rule out. And remember that patients with hip pathology can present with knee pain, and there are innumerable examples of patients who have undergone knee arthroscopy for knee problems that have in fact been coming from hip [problems].”
Nocturnal pain
Patients with hip disease often have nocturnal pain and pain associated with weight bearing; they also often have an antalgic gait, meaning the patient tries to get off their leg quickly. “If somebody limps into your office you shouldn’t be thinking of a lumbar radiculopathy as the first diagnosis – you’re thinking instead of potential hip problems, knee problems or other joint problems.”
Bell stressed that patients with hip disease can sometimes have a negative X-ray, and surgeons who suspect this condition should perform additional tests.
Hip MRI scans are valuable for showing avascular necrosis and other hip pathology. MR arthrograms can show labral tears, loose bodies and the surface of the joint, while hip arthroscopy can help better assess articular surfaces and labral tears.
Many patients with peripheral nerve lesions present with back pain or leg pain, Bell said. These peripheral neuropathy patients often have significant local tenderness around the lesion site.
Neuronal conditions
Jean-Valery Coumans, MD, a neurosurgeon at Harvard Medical School and Mass General Hospital, discussed a number of conditions that can affect the spinal cord and therefore first manifest with back pain.
Researchers have made some links between the onset of multiple sclerosis and another masquerader, acute transverse myelitis. And many neurodegenerative diseases such as amyotrophic lateral sclerosis (AML) can first affect the spinal cord before spreading to the upper and lower motor neurons. This and other neurodegenerative illnesses have a much slower onset than the quick pain associated with acute transverse myelitis, with back and neck pain increasing over weeks and months. EMG tests of the lower extremities can find the presence of AML or other illnesses.
Coumans echoed concerns over nonmechanical causes of spinal pain. “We need to rule out the noncompressive causes of myelopathy, especially when the presentation does not fit the radiographic findings.”
For more information:
- Bell GR, Borenstein D, Coumans JV, et al. Symposium: Masquerade: nonspinal conditions which mimic spinal disease. Presented at the North American Spine Society 19th Annual Meeting. Chicago.