Degenerative, rheumatic, and autoimmune
Degeneration and herniation of the intervertebral disc can cause back or neck pain with radiculopathic pain along the extremity, sometimes without any axial pain whatsoever.6 Piriformis syndrome, which causes sciatic symptoms without back pain, should be excluded.6 Nociceptive nerve fibers in the disc that become sensitized by the cytokines in the degenerative disk cause “pure discogenic” pain.42 In adolescents disc herniation can be associated with separation of the apophyseal ring.28 Non-specific back pain that worsens on standing is related to Modic I changes in the end plate (”active discopathy”).43 Pediatric disc calcification causes a self-limiting neck or back pain.44 Symmetrical buttock pain with perianal hypoesthesia, with or without sphincter weakness, suggests a cauda equina syndrome and requires urgent intervention11 Stenosis of the lumbar spinal canal will cause back and buttock pain during ambulation that may worsen and cause claudication.6 Stenosis of the cervical spinal canal can cause cervical myelopathy with typical ataxia.45 Degeneration of the facet joints will cause ”mechanical” pain on standing, walking, and physical effort. An ”active” osteophyte can appear on every vertebral level, but most typically at the lumbar area, and it will cause pain in the flank that worsens upon movement and is aggravated by nighttime movement. It may be easily diagnosed on a technetium bone scan.6Spondylolisthesis and spinal instability will cause mechanical back pain.6 Costovertebral joint problems (most often osteoarthrosis) will cause localized pain that worsens with movement, coughing, and deep breathing.46 Baastrup syndrome is caused by friction between adjacent spinal processes that produce local inflammation and growth of a bursa. Midline pain and tenderness that improves on flexion and worsens on extension is typically found.47 Diffuse idiopathic skeletal hyperostosis can be asymptomatic or cause back and neck pain.48Spondyloarthropathies, such as ankylosing spondylitis or psoriatic arthritis, will cause axial back or neck pain often involving the sacroiliac joints as well.5 There is typical night pain with prolonged morning stiffness that is relieved by non-steroidal anti-inflammatory drugs.6 Reactive arthritis tends to less involve the spine but it can cause inflammation of the vertebrae and intervertebral joints.31 Bechet’s disease rarely involves the spine and can cause myelitis and vasculitis of the cord.14 Other rheumatic diseases, such as systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) can affect the spine. RA typically involves the upper cervical vertebra and the craniocervical junction, causing atlantoaxial subluxation, superior odontoid migration, or subaxial subluxation.49 SLE can cause myelitis and vasculitis of the cord as well as atlantoaxial subluxation/dislocation.14 Gout can affect the spine at any level, destroying the facet joints and causing hypointense lesions of the gout tophi that are seen in the extradural space on T1-weighted MRIs.31 Clinically, lumbar pain with radiculopathy will most often be observed as in a laterally herniated disc or spinal claudication as seen in spinal stenosis. In levator scapula syndrome, periscapular bursitis of the supraserratus bursa with involvement of the levator scapula will cause pain and local tenderness at the upper medial corner of the scapula.50Inflammation or strain of the rhomboids may cause thoracic back pain, and may be diagnosed by pain and tenderness in the rhomboids. It is important to rule out spontaneous pneumothorax or bulla that can present with a similar type of pain. Fibromyalgia can cause back pain without any physical or laboratory findings except for local tenderness at the known trigger points.14 Myofascial pain syndrome resembles fibromyalgia, but palpable tender and stiff trigger points are found in the muscles and fasciae.51 Polymyalgia rheumatica will cause neck, shoulder girdle, and hip pain, especially in the morning, accompanied by low fever, fatigue, and feeling of illness. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels can be observed, unlike in fibromyalgia.14 Transverse myelitis is an inflammation of the spinal cord, mostly thoracic, that is related to autoimmune or infectious diseases or the use of certain drugs. It affects one or two adjacent segments and causes back or neck pain with motor weakness and complete paraplegia with sphincter paralysis that develops over hours or days.52 Arachnoiditis is chronic inflammation of the arachnoid that is caused by misplaced subdural injection of steroids or contrast medium after spinal operations and various infectious agents. It can be asymptomatic and discovered incidentally on MRI, but it can also cause severe chronic back pain on standing and sitting with various neurological abnormalities related to nerve root or cauda compression.53 Synovitis, Acne, Pustulosis, Hyperostosis and Osteitis (SAPHO) syndrome can affect the vertebra and discs, and cause thickening of the paravertebral tissues.54