Introduction
Neck and back pain are extremely common complaints in orthopedic,
pediatric, emergency room, and general medical
practice.1–3 The range of differential diagnosis of
neck and back pain is vast and even an experienced physician will often
struggle to achieve the correct diagnosis without a systematic approach.
While common diagnoses like a laterally herniated lumbar disc, that is
easily recognizable on the basis of history and physical examination and
can be differentiated from a tumor or a gout tophus, or other
pathologies that can compress the nerve root, by magnetic resonance
imaging, diagnosis of rarer disorders is more difficult. For example,
fungal infections of the spine are almost always diagnosed with a delay
that invariably diminishes the chances of a good
outcome.4 A method of differential diagnosis that
enables the diagnostician to shorten the list of possible diagnoses and
decrease the number of diagnostic tests and the time to final diagnosis
is highly desirable.5
This paper describes a useful method for sorting the possible etiologic
causes according to a short list of simple clinical criteria. Our
intention is to create a kind of map to facilitate the navigation
between the long lists of diagnoses and the appropriate standard tests
and imaging studies for their verification or exclusion with the least
amount of waste in time and resources.
Several recent publications were concerned with the issue of diagnostic
workup for low back pain. The often recommended approaches include its
classification into acute versus chronic pain and consideration of red
flags suggesting more severe pathology.1,6 However,
the reliability and predictive value of red flags in the diagnosis of
severe back pain etiologies has recently been
questioned.7,8 An approach to cervical and thoracic
spine pain is covered in separate publications, but it is largely
extrapolated from literature on low back pain.9 Such
tendency to evaluate different parts of the spine separately may bear a
certain level of risk, because focusing on one anatomical part may
mislead physicians and cause them to neglect other parts. This review
describes a comprehensive and practical systematic approach to the
diagnosis of a patient with axial spinal complaints.