Sudden back pain dds
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"back pain"[MeSH Terms] AND "diagnosis, differential"[MeSH Terms]
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"DDs" most likely means differential diagnoses, so that's what I've covered. Tell me if you meant something else. The list below is for sudden-onset back pain in an adult.
Must-not-miss (exclude first)
| Diagnosis | Clues |
|---|---|
| Aortic dissection | Sudden, severe "tearing" pain in the chest or upper back. Check for a BP difference between arms and a pulse deficit. |
| Ruptured or expanding AAA | Back, flank or abdominal pain with hypotension or a pulsatile mass. |
| Cauda equina syndrome | Urinary retention, saddle anesthesia, bilateral leg weakness, bilateral sciatica. |
| Spinal epidural abscess or hematoma | Abscess: fever, injection drug use, recent spine procedure or bacteremia. Hematoma: anticoagulation or instrumentation. Both are true emergencies needing emergent imaging. |
| Vertebral compression or pathologic fracture | Age over 70, female sex, steroids, osteoporosis, cancer, or minor trauma. |
| Pulmonary embolism, MI, pneumothorax | Chest or upper back pain, often with dyspnea. Sudden onset favors dissection, PE or pneumothorax. |
| Acute myelopathy | Upper motor neuron signs and bladder dysfunction. Needs urgent neuroimaging. |
Sources: [Tintinalli/Rosen EM texts], Table 7-1 in Symptom to Diagnosis; Rosen's Emergency Medicine, Box 31.2.
Other causes by system (Rosen's Box 31.2)
- Spinal:
- Disc herniation with radiculopathy or sciatica
- Acute muscle strain or ligamentous injury
- Spondylolysis or spondylolisthesis
- Spinal stenosis (leg pain worse on walking, relieved by flexion)
- Vertebral osteomyelitis or discitis
- Metastasis or myeloma
- Ankylosing spondylitis
- Transverse myelitis
- Renal: renal colic, pyelonephritis, perinephric abscess.
- Abdominal: pancreatitis, biliary colic, cholecystitis, penetrating peptic ulcer, retroperitoneal hemorrhage, psoas abscess.
- Pelvic: ovarian torsion, PID, ectopic pregnancy, endometriosis, prostatitis.
- Other: herpes zoster (pain before the rash), bacterial endocarditis.
Most likely diagnosis
Nonspecific mechanical back pain accounts for about 95% of back pain in primary care. The usual picture is a clear precipitant, diffuse lumbar or buttock pain, and relief with rest (Symptom to Diagnosis, Table 7-1). It is a diagnosis of exclusion, so go through the red flags first.
Clues that point to a specific cause
- Malignancy: known or active cancer, unexplained weight loss, age over 50, pain lasting over 1 month, nocturnal pain.
- Infection: fever, recent skin or urinary infection, immunosuppression, injection drug use, spine procedure.
- Inflammatory back pain: onset before age 45, insidious onset, morning stiffness over 30 minutes, improves with exercise, wakes you in the second half of the night.
- Radiculopathy: sciatica with an abnormal neurologic exam. Imaging is not urgent unless the deficit is progressing.
- Visceral pain: not affected by movement, colicky (ureter or colon), or associated with abdominal, chest or pelvic symptoms.
Practical workup
- Vitals, both arm BPs, and a pulse exam. Fever, hypotension or tachycardia change the plan.
- Neurologic exam. Include perineal sensation, anal tone, a post-void bladder scan, and lower limb power and reflexes.
- Abdominal and CVA tenderness exam.
- Urinalysis for stones or infection, and a pregnancy test in women of childbearing age.
- If red flags are present: CBC, ESR/CRP and blood cultures for suspected infection.
- Imaging:
- Emergent MRI for cauda equina, suspected epidural abscess or hematoma, or acute myelopathy.
- CT angiography for suspected dissection or AAA.
- Plain films or CT for a suspected fracture.
- No imaging for uncomplicated mechanical pain with no red flags.
Recent evidence check
A PubMed search of systematic reviews and meta-analyses from the last 2 years found nothing that changes this approach. The three results were about diagnostic labels, pain-domain comparisons and terminology.
If you give me age, sex, onset circumstances, and any neurologic, fever, chest or abdominal features, I can narrow this down. If this is a real patient with weakness, bladder or bowel changes, fever, or chest or abdominal pain, they need urgent evaluation.
Sudden severe back pain dds
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"back pain"[MeSH Terms] AND "emergency service, hospital"[MeSH Terms]
Sudden severe back pain has a shorter and more dangerous differential than ordinary back pain. Most of the list below is time-critical, so rule these out before settling on a musculoskeletal cause.
Must-not-miss causes
| Diagnosis | Key features | First test |
|---|---|---|
| Aortic dissection | Pain in the chest, back or abdomen that is abrupt, severe and sharp or tearing, and often migrates as the dissection extends (Schwartz's Principles of Surgery, Diagnostic Evaluation). In type A dissection, 90% report severe or worst-ever pain and 85% report abrupt onset (Symptom to Diagnosis, Table 9-10). High-risk signs are a pulse deficit, a systolic BP difference between arms, and a focal neurologic deficit (Goldman-Cecil, Table 63-2). | CT angiography |
| Ruptured or expanding AAA | Back or abdominal pain is the most common presentation. It is classically severe and abrupt, and about half of patients describe ripping or tearing (Tintinalli's, Clinical Features). Look for hypotension, syncope and a pulsatile mass. | Bedside ultrasound, then CT angiography if stable |
| Spinal epidural hematoma | Sudden severe radicular back pain, then cord or cauda equina signs. Risk factors are anticoagulation, epidural instrumentation, recent spine surgery or trauma. | Emergent MRI |
| Spinal subarachnoid hemorrhage | Excruciating pain at the level of the bleed, which may be radicular or extend into the flank. Headache is possible (Rosen's, Spinal Subarachnoid Hemorrhage). | MRI |
| Spinal cord infarction (anterior spinal artery syndrome) | Sudden back or neck pain, then rapidly progressive paraplegia. Pain and temperature are lost but vibration and position sense are preserved, with sphincter loss (Harrison's; Localization in Clinical Neurology, Table 5-9). Fibrocartilaginous embolism can follow minor trauma (Adams and Victor's). | MRI |
| Cauda equina syndrome | Sudden-onset urinary retention, fecal incontinence, saddle anesthesia and bilateral leg weakness (Grainger & Allison's, Table 47.2). | Emergent MRI |
| Pathologic or osteoporotic vertebral compression fracture | Sudden sharp pain without major trauma, in older adults, steroid users, or patients with cancer (Rockwood and Green's; Rosen's Skeletal Causes). | Plain films or CT, MRI if cord involvement is suspected |
| Pulmonary embolism, MI, pneumothorax | Sudden thoracic or upper back pain. Sudden onset favors dissection, PE and pneumothorax over MI (Rosen's, History). | ECG, troponin, chest X-ray, CT as indicated |
Other important causes
- Renal colic: colicky flank pain radiating to the groin, with hematuria. The patient is restless and cannot find a comfortable position.
- Acute pancreatitis, cholecystitis, perforated or penetrating ulcer: epigastric pain radiating to the back, with an abdominal exam abnormality.
- Retroperitoneal hemorrhage: a patient on anticoagulants, or with a recent procedure.
- Pyelonephritis or perinephric abscess: fever, CVA tenderness.
- Vertebral osteomyelitis, discitis, epidural abscess: usually subacute, but can present abruptly with fever, injection drug use or recent spine procedure.
- Gynecologic causes: ectopic pregnancy, ovarian torsion.
- Acute disc herniation with radiculopathy: sharp back pain with sciatica. Imaging is not urgent unless there is a progressive deficit (Rosen's).
- Acute muscle strain or ligament sprain: a diagnosis of exclusion.
- Herpes zoster: pain before the rash appears.
Sources for the lists above: Rosen's Emergency Medicine, Box 31.2, and Skeletal Causes of Back Pain.
Bedside approach
- Vitals first. Check both arm BPs, pulses, and signs of shock. Fever suggests infection.
- Pain character. Is the onset abrupt, maximal at onset, tearing or migrating? Is it positional or colicky?
- Neurologic exam. Test leg power, sensory level, reflexes, perineal sensation, anal tone, and a post-void residual.
- Abdomen and flank. Palpate for a pulsatile mass, abdominal tenderness and CVA tenderness.
- Risk factors. Ask about anticoagulants, hypertension, Marfan or connective tissue disease, cocaine use, cancer, steroids, injection drug use, recent spine procedure or trauma, and pregnancy.
- Initial tests. ECG, troponin, CBC, creatinine, urinalysis, type and screen, and a pregnancy test. Add bedside ultrasound for AAA.
- Imaging by suspicion. CT angiography for the aorta, emergent MRI for cord or cauda equina compromise, and CT or plain films for fracture.
Suspected dissection, a ruptured AAA, or a new neurologic deficit needs emergent evaluation, not outpatient workup.
Recent evidence check
A PubMed search of systematic reviews and meta-analyses from the last 2 years found only reviews on ED care models for low back pain (for example, PMID 39251477 and PMID 40014896). Nothing there changes the differential above.
If you give me the patient's age, any neurologic or bladder symptoms, vitals, and the exact onset and character of the pain, I can rank these for your case.
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