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