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.