Differential Diagnosis of Acute Low Back Pain

Intrinsic spine

Compression fracture

History of trauma (unless osteoporotic), point tenderness at spine level, pain worsens with flexion, and while pulling up from a supine to sitting position and from a sitting to standing position

Herniated nucleus pulposus

Leg pain is greater than back pain and worsens when sitting; pain from L1-L3 nerve roots radiates to hip and/or anterior thigh, pain from L4-S1 nerve roots radiates to below the knee

Lumbar strain/sprain

Diffuse back pain with or without buttock pain, pain worsens with movement and improves with rest

Spinal stenosis

Leg pain is greater than back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral (foraminal stenosis) or bilateral (central or bilateral foraminal stenosis)

Spondylolisthesis

Leg pain is greater than back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral or bilateral

Spondylolysis

Can cause back pain in adolescents, although it is unclear whether it causes back pain in adults; pain worsens with spine extension and activity

Spondylosis (degenerative disk or facet joint arthropathy)

Similar to lumbar strain; disk pain often worsens with flexion activity or sitting, facet pain often worsens with extension activity, standing, or walking

Systemic

Connective tissue disease

Multiple joint arthralgias, fever, weight loss, fatigue, spinous process tenderness, other joint tenderness

Inflammatory spondyloarthropathy

Intermittent pain at night, morning pain and stiffness, inability to reverse from lumbar lordosis to lumbar flexion

Malignancy

Pain worsens in prone position, spinous process tenderness, recent weight loss, fatigue

Vertebral diskitis/ osteomyelitis

Constant pain, spinous process tenderness, often no fever, normal complete blood count, elevated erythrocyte sedimentation rate and/ or C-reactive protein level

Referred

Abdominal aortic aneurysm

Abdominal discomfort, pulsatile abdominal mass

Gastrointestinal conditions: pancreatitis, peptic ulcer disease, cholecystitis

Abdominal discomfort, nausea\vomiting, symptoms often associated with eating

Herpes zoster

Unilateral dermatomal pain, often allodynia, vesicular rash

Pelvic conditions: endometriosis, pelvic inflammatory disease, prostatitis

Discomfort in lower abdomen, pelvis, or hip

Retroperitoneal conditions: renal colic, pyelonephritis

Costovertebral angle pain, abnormal urinalysis results, possible fever