Back pain — Medicine Library

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Quick guide

Diagnostic approach

Focused clinical evaluation
Order tests based on the suspected etiology of back pain or presence of red flags for back pain.
Cauda equina syndrome or conus medullaris syndrome: MRI L-spine without IV contrast
Vertebral fracture: CT spine without contrast
Spinal epidural abscess or vertebral osteomyelitis: CBC, ESR, CRP, blood cultures, MRI with and without IV contrast
Aortic dissection or AAA rupture: CTA chest, abdomen, and pelvis
Spinal epidural hematoma: CBC, PT, PTT, MRI with and without IV contrast
Malignancy: MRI with and without IV contrast
See “Approach to imaging in back pain.”

Diagnostic testing is not routinely indicated for acute back pain.

Management checklist

Most cases of acute, nonspecific back pain improve without intervention.
Treat acute complications (e.g., Foley catheter placement for acute urinary retention).
Treat the underlying cause.
Conservative management of nonspecific back pain (e.g. NSAIDs).
Order spinal precautions for suspected fracture.
See “Management of traumatic back pain.”
See “Management of compressive spinal emergencies.”

Red flag features

Age < 18 or > 50 years
IV drug use
History of malignancy
History of AAA
Recent trauma or spine surgery
Immunosuppression
Medications (e.g., chronic glucocorticoids, anticoagulation)
Abnormal vitals (e.g., fever)
Signs of aortic pathology (e.g., aortic regurgitation)
Signs of spinal cord compression
Features of compressive myopathies
Pain that is worse at night and/or does not improve with rest

Life-threatening causes

Vertebral fractures
Vertebral osteomyelitis
Spinal cord compression
Spinal epidural abscess
Cauda equina syndrome
Aortic dissection
AAA rupture
Spinal epidural hematoma
Conus medullaris syndrome

Summary

Back pain is experienced by most adults. The majority of cases are benign, nonspecific back pain (pain that is not attributable to a specific pathology). Spinal causes of acute back pain are conditions of the spinal column or surrounding muscles and soft tissue. Spinal causes include conditions that require urgent management to prevent or minimize permanent neurological dysfunction (e.g., spinal cord compression, spinal infections) and nonurgent causes (e.g., inflammatory arthritis, bone metastases without cord compression or unstable vertebral fracture). Nonspinal causes of back pain is referred pain from a thoracic, abdominal, pelvic, retroperitoneal, or cardiovascular cause. Assessment for red flag features of back pain and a focused neurological examination is required in all patients. Initial diagnostics and management should be guided by the pretest probability of the underlying condition. Patients with new neurological findings other than isolated unilateral radiculopathy require immediate imaging, typically MRI, and urgent spinal surgery consultation. Serious and life-threatening nonspinal causes, such as myocardial infarction and aortic pathology, should be considered particularly in patients with abnormal vital signs and no neurological abnormalities. Neurologically intact patients without red flags do not require urgent imaging and typically improve with nonpharmacological treatment options (e.g., superficial application of heat, massage), symptomatic treatment with NSAIDs, and early mobilization.

Classification

By etiology [2][3]

Specific back pain
- Back pain attributable to a pathophysiological condition (e.g., trauma, deformity, disease, injury, or infection); see “Etiology” section for details.
- Mechanical back pain: specific back pain caused by disorders of the spine, intervertebral discs, or surrounding soft tissue [4]
Nonspecific back pain: back pain that cannot be attributed to a specific cause after a full evaluation.
Spinal causes: conditions of the spinal column or surrounding muscles and soft tissue
Nonspinal causes: include thoracic, abdominal, pelvic, retroperitoneal, or cardiovascular conditions that can manifest with referred pain to the back.

By duration [2][5][6]

Acute back pain: pain lasting ≤ 4 weeks
Subacute back pain: pain lasting 4–12 weeks
Chronic back pain: persistent or recurring back pain lasting > 12 weeks

By location

Low back pain (
LBP)
[2]
[3]

Pain localized to the lumbar region (below the costal margin) and above the gluteal folds; may be associated with pain that radiates down the legs

LBP is typically further classified into three broad categories: [7]

Nonspecific LBP (most common) [8]

LBP associated with radiculopathy or spinal stenosis

LBP associated with a specific spinal cause (see “Spinal causes of back pain”)
Upper back pain: pain localized to the thoracic spine region

By severity [9]

Uncomplicated back pain: no red flag features of back pain
Complicated back pain: presence of red flag features of back pain

Epidemiology

2–3% of visits to the ED are for acute nontraumatic back pain. [10]
In the US, low back pain affects up to 85% of individuals and, worldwide, is the leading cause of years lived with disability. [11][12][13]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Trauma can cause both spinal and nonspinal causes of back pain.

Musculoskeletal

Intervertebral disc herniation or disc protrusion
Spinal stenosis
Scoliosis
Spinal osteoarthritis (spondylosis), degenerative disc disease
Spondylolysis, spondylolisthesis
Vertebral fractures
Musculoskeletal spinal injury (back strain)
Rib fractures

Neoplastic

Spinal metastases
Referred pain from primary neoplastic process (e.g., renal cancer, pancreatic cancer)
Primary spinal tumors

Infectious

Spinal epidural abscess
Discitis
Vertebral osteomyelitis
Pott disease

Vascular

Spinal epidural hematoma
Spinal cord infarction

Inflammatory

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis

Referred pain

Cardiovascular: abdominal aortic aneurysm (AAA), aortic dissection, myocardial infarction, pericarditis
Pulmonary: pneumonia, pleurisy, pulmonary embolism
Gastrointestinal: esophageal perforation, esophageal spasm, perforated peptic ulcer, pancreatitis, cholecystitis, cholangitis
Genitourinary: pyelonephritis, prostatitis, nephrolithiasis, hydronephrosis, renal infarction
Other: psoas abscess, retroperitoneal hematoma

Clinical evaluation

Assess for red flag features of back pain in all patients.
Duration of symptoms
Evaluate for psychosocial risk factors
Perform a thorough
neurological examination to assess for any neurological deficits.
- Sensation, power (motor strength), deep tendon reflexes, and superficial reflexes (e.g., Babinski reflex) below the level of the pain bilaterally (including relevant myotomes and dermatomes)
- Signs of radiculopathy/nerve root irritation (e.g., straight leg raise test)
- Perianal sensation and anal tone [10]

Dermatome map Saddle anesthesia

Red flags for back pain

Red flag features on history or clinical examination indicate an urgent or serious underlying etiology.

Red flags for back pain [2][8][10]
	Features
Patient characteristics	Age < 18 or > 50 years Immunosuppression
Relevant medical history	History of cancer or unexplained weight loss [8] History of abdominal aortic aneurysm Recent history of any of the following: Bacterial infection [14] Spinal anesthesia Spinal surgery [15] Significant trauma related to age [2]
Medication use	Long-term glucocorticoid use Anticoagulants IV drug use [15]
Pain characteristics	Pain that does not improve with rest and/or worsens at night Persistent or progressive pain and/or neurological findings despite > 4 weeks of conservative therapy
Examination findings	Fever Abnormal vitals Signs of aortic pathology (e.g., aortic regurgitation, unequal blood pressures) Signs of cord compression syndromes (spinal cord compression, cauda equina syndrome, conus medullaris syndrome), such as: [16] Motor weakness Spasticity and hyperreflexia (upper motor neuron signs) distal to the site of compression Flaccid paralysis and hyporeflexia (lower motor neuron signs) can occur distal to the site of compression in spinal shock. [17] Paresthesias or anesthesia (including saddle anesthesia) Bladder, bowel, or sexual dysfunction

Hypotension and bradycardia in a patient with signs of spinal cord compression are likely indicators of spinal shock. [18]

Pathological fractures, bone metastases, or referred pain (e.g., myocardial infarction, abdominal aortic aneurysm, aortic dissection) are more likely in older individuals with back pain.

Initial management

Perform focused clinical history and examination.
Assess for
red flag features of back pain and risk
stratify accordingly.
- Low suspicion for serious or urgent etiology: supportive care, pain management, close follow-up and return precautions usually sufficient [8]
- High suspicion for serious or urgent etiology: targeted and expedited evaluation to identify and treat the underlying cause, e.g., [10][19]
  
  Concern for spinal infection: urgent MRI with and without IV contrast, empiric antibiotics, neurosurgery consult
  
  Concern for compressive spinal emergency: urgent MRI spine with and without IV contrast, urgent neurosurgery consult; See “Management of compressive spinal emergencies.”
  
  Suspected fracture: spinal precautions, XR spine; See “Management of traumatic back pain.”
Evaluate and treat the underlying cause.
Administer analgesics (preferably NSAIDs) after baseline neurological function and pain severity are documented. [7][10]

Most cases of acute, nonspecific back pain do not require imaging and improve without intervention. [20]

Acute spinal cord compression is a surgical emergency. Obtain immediate MRI or CT myelography, give IV glucocorticoids for malignant compression, and decompress the cord (e.g., with surgery) as soon as possible!

Diagnosis

Imaging [6][7][21][22]

Indications for imaging may include:
[6]
- Suspicion of a serious underlying etiology
- Pain that persists despite at least 4–6 weeks of conservative management.

Approach to imaging in back pain [6][7]
Suspected urgent spinal cause (e.g., severe or progressive neurological deficits, features of spinal infection, features of spinal malignancy, cauda equina)	Urgent MRI spine without and with IV contrast Post-void bladder scan
Suspected inflammatory cause (e.g., ankylosing spondylitis)	X-ray spine
Suspected vertebral fracture	X-ray spine OR CT spine without contrast OR MRI spine without contrast
Isolated radiculopathy and/or clinical features of spinal stenosis without any red flags	Imaging typically not required for acute symptoms [6] Consider MRI spine without IV contrast if symptoms progress or persist despite 4–6 weeks of conservative management. [6]
Suspected nonspinal causes of back pain	Depends on suspected etiology
Nonspecific back pain	Imaging not routinely required Consider MRI spine and possibly x-ray if pain persists for > 6 weeks despite therapy and the patient is a surgical candidate. [6]

In patients presenting with acute back pain without red flags or neurological deficits, imaging is not typically indicated. [7]

Laboratory studies

Laboratory studies are not routinely required for the evaluation of acute or chronic back pain.
Consider obtaining
laboratory studies based on the likely underlying etiology and/or the presence of
red flags for back pain
, e.g.:

CBC and inflammatory markers: for suspected spinal infections, inflammatory arthritis, or malignancy

Blood cultures: for suspected spinal infections

Serum calcium and vitamin D levels: for suspected fragility fractures

Urgent spinal causes of acute back pain

Urgent spinal causes of back pain include conditions that cause, or have the potential to cause, permanent neurological damage or life-threatening complications.
Immediate management is required for patients with severe and/or progressive neurological deficits. [10]

Overview of urgent spinal causes of back pain
	Characteristic clinical features	Diagnostic findings	Management
Compressive spinal emergencies [17][23]	Risk factors for spinal cord compression Sudden severe back pain or radicular pain Neurological deficits below the level of the lesion (including urinary retention, saddle anesthesia, fecal incontinence)	Urgent MRI spine without and with IV contrast Edema of the spinal cord or cauda equina Extrinsic compression Post-void residual	Urgent surgical decompression (neurosurgery consult) Treat the underlying cause. Suspected malignant cord compression: high-dose IV dexamethasone Urinary catheter if indicated See “Management of compressive spinal emergencies”
Vertebral fractures (pathological or traumatic)[24]	Trauma significant for age Localized vertebral pain and/or contusion Uneven alignment of the vertebral spinous processes Chronic corticosteroid use	X-ray spine: Vertebral misalignment ↓ vertebral body height or wedging [6][25]	Immediate spinal precautions Unstable vertebral fractures or cord compression: Urgent neurosurgery consult Surgical stabilization (spondylodesis) Surgical decompression for cord compression Stable vertebral fractures without cord compression: Conservative management Vertebroplasty or kyphoplasty
Spinal infections [26]	Risk factors for spinal infection Fever, rigors Tender point Limited spine mobility Signs of spinal cord compression	↑ WBC and inflammatory markers Blood cultures : Staphylococcus aureus (most common) [26] Urgent MRI with and without IV contrast: inflammation, abscess : [6]	Empiric antibiotic therapy for spinal infection Urgent neurosurgery evaluation
Spinal epidural hematoma causing cord compression [27]	Possible history of: Thrombocytopenia Bleeding disorders Use of anticoagulants Vascular malformations Localized trauma (e.g., following lumbar puncture, pulling of the epidural catheter)	MRI with and without IV contrast [28] Blood in the epidural space with a smooth contour [28] Loss of epidural fat signal	Strict bed rest Anticoagulant reversal, if indicated Urgent neurosurgery consult for surgical decompression (laminectomy and evacuation of blood)

Acute urinary retention in a patient with sudden back pain and neurological deficits is strongly suggestive of cauda equina syndrome (90% sensitivity). [7]

Spinal boards should only be used for transport; remove patients from them on arrival at the hospital to reduce pain and prevent the development of pressure ulcers!

Cervical disk herniation $Thoracic wedge compression fracture$ Chronic lumbar compression deformity $T12 burst fracture and L1 fracture$ $Vertebral arch fracture deformity with spinal stenosis$ $Burst fracture of T12 vertebral body$ $Acute and chronic vertebral fractures$ Retropharyngeal abscess with spondylodiscitis and osteomyelitis Spinal epidural abscess, osteomyelitis, and discitis Spinal epidural hematoma

**Vertebral arch fracture deformity with spinal stenosis**
CT cervical spine (bone window; axial plane)
There is a fracture deformity of the right vertebral arch (green overlay) with depression causing narrowing of the spinal canal.

Source: © IMPP

**Burst fracture of T12 vertebral body**
CT thoracic spine (T12 level; left: sagittal plane; right: axial plane; bone window)
A compression fracture of the superior endplate (red overlay and lines) is accompanied by cortical disruption and retropulsion (arrow) into the spinal canal.
Burst fractures result from high-energy axial compression forces accompanied by varying degrees of flexion and/or rotation. They can be stable or unstable fractures.

Source: “Figures 1 and 2, in: A Smart Technique to Remove Ruptured Inflatable Bone Tamp From the Vertebral Body in Balloon Kyphoplasty” by Papaioannou I , Mousafeiris VK, Pantazidou G, Repantis T, Korovessis P, Cureus, licensed under CC BY 4.0. Modifications: images combined and cropped, arrows removed. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Acute and chronic vertebral fractures**
MRI lumbar spine (left: STIR image; right: T1-weighted; sagittal plane)
Compression deformities of the T8, T10, and L4 vertebrae (green overlays) are visible. The T8 and T10 fractures are hyperintense on the STIR image, indicating that they are recent. The compressed superior endplate of L4 is iso- to hypointense, indicating an old or chronic deformity. The hypointense appearance of the L2–3 intervertebral disc (green circle) on the STIR image indicates disc degeneration.

Source: © IMPP

**Thoracic wedge compression fracture**
X-ray thoracic spine (lateral view) of a patient with osteoporosis
There is an insufficiency fracture of the T7 vertebral body, which is anteriorly wedged (green overlay) and accompanied by anterior subluxation (arrow) of the T6 vertebral body.
Wedge compression deformities are frequently osteoporotic, although alternatively may be pathologic (secondary to a focal bone lesion) or traumatic.
Red dashed outlines: normal vertebrae

Our great thanks to Dr. Kissig (Center for Diagnostic and Interventional Radiology, Hedwigshöhe, St. Hedwig, Berlin, and St. Josefs Hospital, Potsdam) for kindly providing this image.

**Chronic lumbar compression deformity**
X-ray lumbar spine (lateral view)
There is a chronic compression deformity (red dimension line) of the L4 vertebral body, with displacement (red overlay) toward the spinal canal beyond the posterior vertebral lines of L3 and L5 (white dotted line). Exuberant anterior osteophyte formation is visible at L3–4 (red dotted lines).

Source: © IMPP

**Retropharyngeal abscess with spondylodiscitis and osteomyelitis**
MRI cervical spine (T2-weighted; sagittal view)
A large, well-defined, T2-hyperintense structure in the neck, representing a fluid collection (blue overlay), is visible between the pharynx and the C1–C5 vertebrae and extends superiorly to the clivus. The C3 and C4 vertebral bodies (green overlay) demonstrate higher signal intensity than the other vertebral bodies, consistent with bone edema. The C3–4 intervertebral disc (red overlay) also demonstrates higher signal intensity than the discs at other levels. There is signal representing fluid in the epidural space at the level of C2–C4 (yellow overlay).
The differential diagnosis for a retropharyngeal fluid collection includes abscess, hematoma, and effusion. Bone marrow edema can result from, e.g., infection, osteoarthritis, and trauma. In this case, the large fluid collection near the edematous vertebrae and intervertebral disc edema raise suspicion for infection of these structures. The retropharyngeal abscess may have preceded the development of spondylodiscitis and the epidural collection, since the vertebral findings are relatively early, with no evidence of destructive changes.

Source: © IMPP

**Spinal epidural abscess, osteomyelitis, and discitis**
MRI cervical spine (T2-weighted; sagittal plane)
High signal intensity collections are seen in the posterior epidural space. The largest collection (blue overlay) causes anterior displacement and high-grade compression of the spinal cord from C7-T2. The appearance is consistent with epidural abscess. The differential would also include epidural hematoma.
High signal intensity consistent with osteomyelitis and discitis involves the C6 and C7 vertebral bodies (green overlay), prevertebral soft tissues (red overlay), and intervening disc space (yellow overlay).

Source: “Figure 1, in: A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture” by J. J. Chan, J. J. Oh, BMC - International Journal of Emergency Medicine, licensed under CC BY 4.0. Modifications: cropped white rim. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Spinal epidural hematoma**
MRI cervical spine (T2-weighted; sagittal plane) of a 58-year-old patient on long-term warfarin therapy presenting with acute tetraplegia
A region of heterogeneous signal lies along the posterior aspect of the spinal canal (indicated by arrows), between the dura and vertebral canal, representing a hematoma. The hematoma displaces the spinal cord anteriorly and compresses it, most prominently between the levels of C3 and C7. At the level of C7, there is an oval area of hyperintense signal within the spinal cord (arrowhead), representing myelopathic change (injury to the spinal cord).

Source: “Fig. 1, in: Anti-coagulation Drug Warfarin Contributes to Severe Adverse Outcomes in Prolonged Unsupervised Use: A Double-edged Sword” by Ordookhanian C, Kaloostian SW, Kaloostian PE, Cureus, licensed under CC BY 3.0. Modifications: Arrows have been removed. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

Compressive spinal emergencies

The following table outlines common symptoms following compression of the spinal cord or cauda equina. Patients may also present with symptoms of incomplete spinal cord syndromes depending on the location of compression.

Spinal cord compression, conus medullaris syndrome, and cauda equina syndrome are medical emergencies that have the potential to cause permanent neurological damage. [10]

Overview of compressive myelopathies [17]
	Spinal cord compression	Conus medullaris syndrome	Cauda equina syndrome
Etiology	Damage to or compression of the spinal cord at any level due to: Degenerative disc disease Neoplasms Vertebral metastases Trauma (epidural hematoma, vertebral fracture) Epidural abscess	Damage to or compression of the spinal cord at the vertebral level T12–L2, resulting in injury to the conus medullaris (sacral and coccygeal spinal segments) [29][30] Common causes include spondylolisthesis, tumors, and trauma (e.g., vertebral fracture).	Damage to or compression of the cauda equina (nerve fibers L3–S5) located below L2 Common causes include large posteromedial disc herniation, trauma, and tumors.
Onset	Variable, bilateral	Sudden, bilateral	Gradual, typically unilateral
Pain	Localized neck or back pain	Lower back pain Less severe radicular pain	Lower back pain Severe radicular pain
Motor symptoms	Bilateral paralysis below the affected level of the spinal cord Hyperreflexia Positive Babinski sign Ataxia	Symmetric, hyperreflexic distal paresis of lower limbs, possibly fasciculations Achilles reflex may be absent.	Asymmetric, areflexic, flaccid paresis of the legs Muscle atrophy
Sensory symptoms	Loss or reduction of all sensation below the affected level of the spinal cord	Symmetric bilateral perianal numbness Sensory dissociation	Saddle anesthesia: lack of sensitivity in the dermatomes S3–S5, affecting the areas around the anus, genitalia, and inner thighs (may be asymmetric) Asymmetric unilateral numbness and/or paresthesia in lower limb dermatomes
Urogenital and rectal symptoms	Sphincter dysfunction with urinary or bowel urgency, retention, or incontinence	Early onset of bladder and fecal incontinence Erectile dysfunction	Late onset of urinary retention Change in bowel habits due to loss of anal sphincter control Decreased rectal tone or bulbocavernosus reflex Erectile dysfunction

Conus medullaris and cauda equina syndromes Saddle anesthesia

Cauda equina syndrome typically manifests with lower motor neuron signs. Spinal cord compression and conus medullaris manifest with a combination of lower motor neuron signs (at the level of compression) and upper motor neuron signs (below the level of compression).

Management of compressive spinal emergencies

Urgent MRI spine without contrast
Consult neurosurgery for urgent surgical decompression.
Document the patient's current neurological deficits and reassess frequently. [31]
Bladder scan to evaluate postvoid residual; Insert Foley catheter for patients with urinary retention.
Administer analgesics (preferably NSAIDs, see “Pain management”). [7][10]
Treat the underlying cause (e.g., suspected malignant cord compression: high-dose IV dexamethasone ) [32]
Admit the patient for frequent neurological examinations and definitive management.

Treatment of acute spinal cord compression varies based on the underlying etiology and may include decompressive surgery (e.g., for disc herniation) or IV steroids and radiation therapy (for malignant compression).

**Conus medullaris and cauda equina syndromes**
1 (conus medullaris syndrome): disc herniation at L1-L2 with pressure on the conus medullaris
2 (cauda equina syndrome): disc herniation at L3-L4 with pressure on the cauda equina
While disk herniation has been used to illustrate the process here, any pathology that compresses the conus medullaris or cauda equina can result in these syndromes.

© AMBOSS

Nonurgent spinal causes

Overview of nonurgent spinal causes of back pain [21]
	Characteristic clinical features	Diagnostic findings	Management
Back strain	Triggering event Localized pain that worsens with movement and palpation	Clinical diagnosis	See “Nonspecific LBP.” Non-low back muscle injury [33] Topical NSAIDs Oral NSAIDs or oral acetaminophen as needed
Symptomatic degenerative disc disease (without cord compression) [34][35][36]	Risk factors for degenerative disc disease Back pain (often L5–S1) with or without radiculopathy (e.g., sciatica) Worsened by coughing/sneezing Positive straight leg raise test (for intervertebral disc herniation)	MRI spine without contrast may show any of the following : [8] Intervertebral disc herniation or prolapse	Isolated radiculopathy and no red flags: conservative management Pain management Physiotherapy Continuation of usual activity (minimize bed rest) Persistent or severe neurological deficits: surgery (discectomy)
Spinal stenosis [37][38]	Risk factors for spinal stenosis Neurogenic claudication	MRI spine without IV contrast: Narrowed spinal canal [6][19]	Mild or moderate symptoms: conservative management (e.g., NSAIDs, physical therapy, epidural steroid injection) Severe or persistent symptoms: surgery (high recurrence rate)
Uncomplicated spinal metastases [8]	History of cancer Nonspecific symptoms (weight loss, night sweats) Deep dull pain; worse at night Localized pain (often thoracic) [8]	Labs suggestive of underlying malignancy MRI with IV contrast: confirmation of tumor size and spinal cord involvement	Consult oncology and spine surgery. [39] Consider osteoclast inhibitors. [40]
Inflammatory back pain (e.g., ankylosing spondylitis, reactive arthritis, psoriatic arthritis) [8][41]	Risk factors for inflammatory arthropathies Insidious onset of lumbar pain or stiffness that : [41] Lasts ≥ 3 months [41] Improves with exercise or NSAIDs Worsens at rest Extraarticular symptoms Restricted spinal mobility	CBC: ↑ WBC, anemia ↑ Inflammatory markers Autoantibodies may be positive. HLA-B27: may be positive in patients with ankylosing spondylitis X-ray of sacroiliac joints and lumbar spine: sacroiliitis	Consult rheumatology. NSAIDs, DMARDs Physical therapy Surgery in severe cases
Spondylolisthesis [42][43]	Risk factors for spondylolisthesis [44] Possible radiculopathy symptoms of neuropathic claudication Gait abnormalities Step-off sign (in advanced stage)	X-ray spine lateral view (preferred): anterolisthesis , spondylolysis [6]	Conservative management Severe or persistent symptoms: surgery

In young adults with back pain that does not improve with rest or medication and/or worsens at night, suspect inflammatory arthritis.

Patients with unilateral neurological symptoms resulting from radiculopathy typically do not require urgent spinal surgical management.

Degenerative disk disease with disk extrusion Spinal disk herniation with migration (1/3) Lumbar spinal stenosis Vertebral metastasis Sacroiliitis Bilateral sacroiliitis in ankylosing spondylitis Lumbar ankylosing spondylitis Lumbar spondylosis Spondylolysis (Scottie dog sign with collar) Spondylolisthesis Right convex thoracic scoliosis

**Spinal disk herniation with migration (2/3)**
MRI lumbar spine (T2-weighted, axial plane)
Extruded disk material (green overlay) has migrated to the level of the L5 vertebral body and is compressing the thecal sac posteriorly.
V: vertebral body; SP: spinous process

Source: © IMPP

**Spinal disk herniation with migration (3/3)**
MRI lumbar spine (T2-weighted; sagittal plane)
The desiccated disk at L4–5 is hypointense and the disk space is narrowed. Extruded disk material (green overlay) has migrated to the level of the L5 vertebral body and is compressing the thecal sac.
Hatched green overlay: normal intervertebral disks

Source: © IMPP

**Lumbar spinal stenosis**
MRI lumbar spine (T2-weighted; sagittal plane)
Advanced degenerative changes (red overlay) involve the intervertebral disks and posterior elements at multiple levels. The spinal canal (green overlay) is narrowed at L2–3 and L3–4 (indicated by arrows).
White dashed outline: spinal cord

Source: © IMPP

**Vertebral metastasis**
MRI spine (A: T1-weighted, scout/localizer; B: T1-weighted, sagittal view) of a 52-year-old man with low back pain.
Image A: Vertebral body height loss of T8 and T11 (triangles) with diffuse hypointense signal, representing pathological compression fractures.
Image B: Numerous hypointense lesions (arrowheads) demonstrated in the vertebral bodies of T11, L1-L4, and the sacrum.
The hypointense lesions represent osseous metastasis. In this example, the primary tumor was a lung adenocarcinoma. Bone marrow is normally bright on T1 sequences due to the presence of fat. Loss of fat signal indicates replacement of fat with other tissue. In this example, the fat is replaced with tumor cells.

Source: “Figure 1, in: Lung Cancer With Vertebral Metastases Presenting as Low Back Pain in the Chiropractic Office: A Case Report” by Chu E, Trager R J, Lee W, et al., Cureus, licensed under CC BY 4.0.

**Sacroiliitis**
X-ray lumbar spine (AP view; supine position) of a patient with ankylosing spondylitis
Characteristic findings of sacroiliitis are visible on the sacroiliac joints, including extensive periarticular sclerosis (green overlay) and erosions (example indicated by red overlay).

Source: © IMPP

**Spondylolisthesis**
X-ray lumbar spine (lateral view)
Anterior displacement (green overlay) of L4 on L5 is visible (Meyerding grade II). In addition, there is degenerative disk disease with narrowing of the L4–L5 disk space (red overlay), as well as hypertrophic changes of the L5 vertebral body.

Source: © IMPP

**Bilateral sacroiliitis in ankylosing spondylitis**
CT pelvis (axial plane; bone window)
Typical changes in ankylosing spondylitis can be seen, with multiple sites of erosion (examples indicated by green overlay) and sclerosis (examples indicated by red overlay). The courses of the sacroiliac joints (green dashed lines) are poorly visualized as a result of regions of narrowing and fusion across the joint spaces.
1: sacral foramina; 2: sacral canal

Source: © IMPP

**Ankylosing spondylitis**
MRI spine (T2-weighted; sagittal plane)
Multiple hyperintense vertebral lesions (green overlays) correlate with sites of inflammation (spondylitis). The L4–5 disk space is narrowed and irregular (red overlay), and the anterior superior corner of L5 is fractured (red arrowhead). Syndesmophytes (examples indicated by green arrowheads) are visible at multiple levels.

Source: © IMPP

**Lumbar ankylosing spondylitis**
X-ray lumbar spine (lateral view)
Marginal syndesmophytes (red lines) from ossification of the annulus fibrosis bridge multiple lumbar vertebrae (known as “bamboo spine”). So-called “shiny corners” (green triangles) at the superior and inferior margins of vertebrae represent reactive sclerosis in response to inflammatory Romanus erosions. Lower lumbar facet joints are fused (green lines).

Source: © IMPP

**Lumbar spondylosis**
X-ray lumbar spine (left: AP view; right: lateral view)
There are degenerative changes, with large osteophytes (examples indicated by green overlay) projecting from the anterior and lateral aspects of several vertebral endplates. Some adjacent vertebrae are fused by bridging osteophytes (examples indicated by arrows).

Source: © IMPP

**Spondylolysis (Scottie dog sign with collar)**
X-ray lumbar spine (45° oblique view)
The normal Scottie dog sign (green overlay) has a collar (red overlay) as a result of a defect in the pars interarticularis (spondylolysis).

Source: © IMPP

**Right convex thoracic scoliosis**
X-ray spine (left: frontal view, right: lateral view)
A severe scoliotic curvature is seen, with the Cobb angle (green overlay) of the major curve (MC) measuring 80° and the Cobb angle (red overlay) of the compensatory curve (CC) measuring 50°.
A scoliosis radiograph is generally performed PA (posteroanterior) rather than AP in order to reduce breast dose. A lateral radiograph is sometimes additionally obtained.
The Cobb angle measures the maximal angle between tangents placed along the upper endplate of the superior-end vertebra and the lower endplate of the inferior-end vertebra of the scoliotic curvature. Particularly if the tangents do not intersect, the Cobb angle is measured at the point of intersection between perpendicular lines drawn at each of the tangents. A Cobb angle in the range of 10-20° is considered to denote mild scoliosis, between 20-40° moderate scoliosis, and >40° severe scoliosis.

Source: © IMPP

Nonspinal causes (referred pain)

Nonspinal back pain is referred pain that originates outside of the spinal cord, vertebral column, and back muscles. [7]

Overview of nonspinal causes of back pain
	Characteristic clinical features	Diagnostic findings	Initial management
Abdominal aortic aneurysm (AAA) [45]	Risk factors for AAA LBP [46] Pulsatile abdominal mass Bruit on auscultation	Ultrasound abdomen or CTA (stable patients): dilatation of the aorta ≥ 3 cm [47]	Vascular surgery consult Small aneurysms with low risk of rupture: AAA surveillance
Aortic dissection [48][49]	Risk factors for aortic dissection Severe, tearing chest pain that radiates to the back Symptoms of myocardial ischemia Signs of hypoperfusion Asymmetric blood pressure and pulses New diastolic murmur	Elevated D-dimer [49] Screening CXR or TTE (for unstable patients) MRA/CTA of the chest, abdomen, pelvis (in stable patients): intimal flap with false lumen	Hemodynamic monitoring and blood pressure control Urgent cardiothoracic surgery consult Anticoagulant reversal, if indicated
Retroperitoneal hematoma [50][51][52]	Risk factors for retroperitoneal hematoma Flank pain Hypovolemic shock (if hematoma is large)	↓ Hemoglobin and hematocrit Possible abnormal coagulation parameters CT abdomen and pelvis with IV contrast/CTA: fluid in retroperitoneal space [53][54]	Intravascular volume repletion Anticoagulant reversal Urgent surgery and/or interventional radiology consult for source control [55]
Psoas abscess [56]	Risk factors for psoas abscess Classic triad low back pain, antalgic gait, fever [57] Ipsilateral hip in flexed position at rest Pain on passive extension and/or internal rotation of the ipsilateral hip Palpable mass (may be tender) in the ipsilateral inguinal or iliac region	↑ WBC and inflammatory markers Positive cultures [58] CT abdomen and pelvis with IV contrast: enlarged psoas muscle; encapsulated hypodense lesion [59]	Empiric antibiotic therapy for psoas abscess Surgery and radiology consult for drainage (percutaneous or open surgical)
Pyelonephritis [60]	Risk factors for pyelonephritis Fever, chills Flank pain Dysuria, urgency	↑ WBC and inflammatory markers Normal or ↓ renal function Urinalysis findings of UTI Positive urine culture	Empiric antibiotic therapy for complicated pyelonephritis Empiric antibiotic therapy for uncomplicated pyelonephritis
Ureteric colic [61][62]	Risk factors for nephrolithiasis Severe, unilateral, colicky flank pain Nausea and vomiting Hematuria	Hematuria on urinalysis Normal or ↓ renal function CT abdomen and pelvis without contrast: visible stone, ureteric dilatation, hydronephrosis [63]	Stone ≤ 10 mm: tamsulosin Stone ≥ 10 mm: urgent urology consult for interventional management Antibiotics for concurrent UTI

Lumbar spine erosion from abdominal aortic aneurysm Ruptured aortic aneurysm Widened mediastinum Aortic dissection (Stanford A) Transesophageal echocardiography of aortic dissection Retroperitoneal hemorrhage from the left common iliac artery Left retroperitoneal hemorrhage Psoas abscess Acute pyelonephritis and renal calculi Nonobstructive renal calculus Acute pancreatitis Hypoechoic pancreas in acute pancreatitis (interstitial edematous pancreatitis) Acute calculous cholecystitis Gallbladder wall thickening Acute acalculous cholecystitis with sludge Acute cholecystitis

**POCUS (abdomen): aortic aneurysm**
Short video of an ultrasound examination of the abdominal aorta in short axis view (a marker indicates the probe position) showing an aneurysm with a thrombus that narrows the lumen.
The abdominal aorta is seen in cross-section in the center of the image. The anechoic area in the lumen of the aorta corresponds to the expected appearance of flowing blood; the semilunar structure on the right side of the lumen is a thrombus (yellow overlay).

Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.

**Ruptured aortic aneurysm**
Click on the overlay icon below the taskbar on the left to toggle the overlay on and off.

CT abdomen (with contrast; arterial phase; axial plane)
An infrarenal abdominal aortic aneurysm is measured as 8 cm in transverse diameter. Contrast extravasation (dashed outline) is seen on the left side at the site of rupture (arrowhead). A large left retroperitoneal hematoma (yellow overlay) extends inferiorly into the inguinal canal. Additional intraperitoneal fluid is seen in the pelvis and right upper quadrant (red overlay).

Created by: Nándor Faluhelyi. Organization providing image: University of Pécs, Medical School. Further notes: Our great thanks to Nándor Faluhelyi (University of Pécs, Medical School) for kindly providing this case.

**Aortic dissection (Stanford A)**
CT chest (with contrast; oblique sagittal reconstruction)
A complex Stanford type A dissection is seen, which involves the ascending aorta, arch, and descending aorta.
1: descending aorta; 2: left subclavian artery; 3: ascending aorta; red arrowheads: dissection flap

Source: “AoDiss CTRekonstr” by Dr. Lars Grenacher, Wikimedia Commons; www.grenacher.de, licensed under CC BY-SA 3.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 3.0.

**Retroperitoneal hemorrhage from the left common iliac artery**
CT abdomen (with contrast; coronal plane) of a patient with abdominal pain after lumbar discectomy
The large collection with irregular margins in the left retroperitoneum represents hemorrhage (H; green overlay). The site of active bleeding is indicated by contrast-enhanced blood (bright green overlay) arising from the proximal left common iliac artery (CIA).
PV: portal vein; K: kidney; GB: gallbladder; A: aorta

Source: © IMPP

**Left retroperitoneal hemorrhage**
CT abdomen (with contrast, axial plane; soft tissue window) of a patient who fell from a height
Non-enhancing left retroperitoneal collections with fascial stranding are consistent with retroperitoneal hemorrhage (green overlay). The left kidney is anteriorly displaced.
Acute and subacute retroperitioneal hemorrhages often contain areas of high attenuation (i.e., attenuation greater than muscle). Older hemorrhages typically present as low attenuation collections.
A homogeneous, circular, and well-circumscribed lesion with a thin wall (red overlay) is visible in the posterior left kidney. The lesion measured fluid density consistent with a simple renal cyst.

Source: © IMPP

**Psoas abscess**
CT lumbar spine (without contrast; axial plane; soft tissue window)
The left psoas muscle is enlarged by a hypodense mass (green overlay). Involvement also extends to the level of the adjacent neural foramen and posteriorly to obliterate fat planes of the paraspinal musculature.
Findings represent a psoas abscess with paraspinal extension.

Source: “ParaspinalabscessCorMark” by James Heilman, MD, Wikimedia Commons, licensed under CC BY-SA 4.0. Modifications: removed arrow. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 4.0.

**Nonobstructive renal calculus**
CT abdomen (with oral contrast; coronal plane)
A nonobstructive hyperdense calculus (red circle) is present in the left renal pelvis. Atherosclerotic calcifications (red arrowheads) of the abdominal aorta (red overlay) are also seen. Metal streak artifacts (white arrows) between the aorta and inferior vena cava (blue overlay) are caused by an internal spinal fixator.
K and dashed lines: kidney; Li: liver, Lu: lung; PM: psoas major muscle; S: stomach with oral contrast; UB: urinary bladder

Our great thanks to Dr. Kissig (Center for Diagnostic and Interventional Radiology, Hedwigshöhe, St. Hedwig, Berlin, and St. Josefs Hospital, Potsdam) for kindly providing this image.

**Widened mediastinum**
X-ray chest (PA view) of a patient with a Stanford type A dissection
Widening of the mediastinum is accompanied by a prominent aortic knob on the left side (green dashed line) and convexity in the region of the ascending aorta on the right side (red dashed line). Cardiac silhouette enlargement is also visible (black arrow line), which could indicate aortic regurgitation or pericardial effusion.
Orange dashed line: proximal descending aorta

Source: “AoDiss ChestXRay” by J. Heuser, Wikimedia Commons, licensed under CC BY-SA 3.0. Modifications: delete measurements. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 3.0.

**Transesophageal echocardiography of aortic dissection**
Echocardiography (transesophageal; transverse view)
The descending thoracic aorta shows a crescentic false lumen and rounded true lumen.

Source: “Figure 4 in: Transesophageal echocardiographic evaluation of an intraoperative retrograde acute aortic dissection: case report” by William C Culp Jr, Karen J Morgan-Vanderlick & Charles G Reiter, BMC Cardiovascular Ultrasound, licensed under CC BY 2.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Acute pyelonephritis and renal calculi**
CT abdomen (with IV contrast; venous phase; axial plane) of a patient with acute pyelonephritis
The left ureter and renal pelvis are slightly dilated (red overlay) and contain hyperdense calculi (white arrowheads). The left kidney is larger than the right and the left renal parenchyma (green overlay) shows reduced contrast enhancement. There is also perinephric stranding (yellow overlay and white arrow), which is an important sign of renal inflammation or obstruction.
V: inferior vena cava; A: aorta

Source: © IMPP

**Pyelonephritis**
Ultrasound kidney (longitudinal plane)
The renal sinus and cortex (C) are not well differentiated from one another. Much of the central kidney is replaced by a poorly marginated area of hyperechogenicity (green overlay).

Source: “Figure 26, in: Ultrasonography of the Kidney: A Pictorial Review” by Kristoffer Lindskov Hansen, Michael Bachmann Nielsen, Caroline Ewertsen, Diagnostics, licensed under CC BY 4.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Acute pancreatitis**
CT abdomen (with contrast; axial plane) of a patient with acute biliary pancreatitis
Fatty and fascial stranding (yellow overlay) anterior to the pancreas (P) indicates peripancreatic inflammation. The gallbladder (yellow outline) contains calculi (examples indicated by red overlay) and sludge. In addition, the common bile duct (green overlay) is slightly dilated.
The passage of a gallbladder calculus through the common bile duct can result in acute pancreatitis.
A: aorta; Vc: ascending vena cava; L: liver; Sp: spleen; Red arrow: hepatic artery; Green outline: stomach

Source: © IMPP

**Hypoechoic pancreas in acute pancreatitis (interstitial edematous pancreatitis)**
Ultrasound abdomen (transverse plane) of a patient with a history of pancreatitis
Portions of the pancreatic head (H), neck (N), and body (B) are seen. The tail is not well visualized (indicated by arrowheads). The visible pancreas is diffusely hypoechoic and lobulated.
Ultrasound is often used as a frontline tool to assess the pancreas. It is frequently used to assess for biliary dilatation and calculi in the setting of suspected pancreatitis. The pancreas may be obscured by bowel gas, particularly in the presence of an ileus, but a visible inflamed or necrotic pancreas may appear enlarged, hypoechoic, or heterogeneous. Ultrasound can be used to guide therapeutic interventions and help monitor the evolution of peripancreatic fluid collections that may accompany pancreatitis.

L: liver; S and dashed line: spine

Source: “Acute-pancreatitis-20.jpg” by Iqra Qamar, wikidoc.org, licensed under CC BY-SA 3.0. Modifications: - box and description removed. The supplementary image with overlays of relevant areas was adapted from the image mentioned above and licensed under CC BY-SA 3.0.

**Acute calculous cholecystitis**
Ultrasound gallbladder
The gallbladder is dilated and its wall (green overlay) is thickened and striated (alternate hyperechoic and hypoechoic layers) as a result of edema. A calculus within dependent sludge in the neck produces posterior acoustic shadowing (red overlay) and has a highly reflective echogenic anterior surface (green hatched overlay).
Ultrasound findings in acute cholecystitis include wall thickening, dilatation, pericholecystic fluid, and a positive sonographic Murphy sign. The presence of multiple ultrasound findings increases diagnostic accuracy for cholecystitis.
L: liver

Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.

**Gallbladder wall thickening**
Ultrasound gallbladder (transverse plane)
The gallbladder wall is thickened. Edema has produced a striated or layered appearance with hyperechoic inner and outer layers (green overlay) and a more hypoechoic middle layer (red overlay).
These features are suggestive of acute cholecystitis.
L: liver

Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.

**Acute acalculous cholecystitis with sludge**
Ultrasound gallbladder (transabdominal; longitudinal plane)
The gallbladder is dilated and its wall (red overlay) is thickened. The layered appearance of the wall (hypoechoic stripe between two echogenic lines) is the result of inflammation and edema. Dependent biliary sludge (green overlay) is visible.
Many diseases cause gallbladder wall thickening. Ultrasound findings in acute acalculous cholecystitis can include mural thickening, dilatation, pericholecystic fluid, hyperemia, and a positive sonographic Murphy sign. The presence of several ultrasound criteria increases diagnostic accuracy for cholecystitis. In this case, the additional feature of gallbladder distention was helpful.

Our great thanks to sono.gallery, a medical ultrasound library by Dr. Daniel Merkel, for providing the images and videos.

**Acute cholecystitis**
CT abdomen (with IV and oral contrast; axial plane)
The gallbladder wall is thickened (green overlay) and has a layered appearance, with hypodense edema between layers of mucosa and serosa. Hyperenhancement of the adjacent liver (red overlay) may reflect increased hepatic arterial flow in response to gallbladder inflammation.
K: kidney; S: stomach; B: small bowel

Source: © IMPP

Nonspecific back pain

Nonspecific back pain is the most common type of back pain and accounts for the majority of cases of low back pain (LBP). [7]

Definition

Pain that cannot be attributed to an underlying disease or structural lesion after a full evaluation

Risk factors [3][64]

Poor posture
Sedentary lifestyle, low level of physical activity
Heavy lifting
Older age
Psychological stressors (e.g., stress, anxiety, depression)
History of lumbar surgery [6]

Clinical features [4][7][8]

Typically LBP
Evaluation of back
pain does not reveal an underlying cause.
- No red flags for back pain [10]
- Normal neurological examination [8]
- No features suggestive of specific back pain (e.g., negative straight leg raise test)
Usually resolves spontaneously within 6 weeks [2][65]

Imaging [3][4][6]

Imaging is not routinely recommended for the evaluation of nonspecific LBP.

Indications
- Progressive symptoms during conservative management
- Persistent symptoms despite 6 weeks of conservative management (if the patient is a surgical candidate)
Modalities
- MRI lumbar spine without IV contrast
- X-ray lumbosacral spine
- CT lumbar spine without IV contrast

Management [2][3][4][5][66][67]

Reassure patients and provide patient education.
Initiate conservative management alone or in combination with nonselective NSAIDs.
For patients with risk factors for chronic back pain, consider more intensive therapy and multidisciplinary involvement.
Reassess symptoms in 4–6 weeks or earlier if symptoms worsen during conservative management.
Persistent symptoms despite
6 weeks of
conservative management
- Consider alternative causes of back pain.
- Consider imaging for back pain if there is diagnostic uncertainty or to evaluate candidacy if surgery is being considered. [6]
- Consider referral to specialists. [2]

Patient education [2][4][5][66]

Maintain daily activities, including work and sports; avoid bed rest. [2][10]
Stretching, exercises, and appropriate ergonomics for LBP
Avoid movements that aggravate pain
Reassurance and expectation management
Self-management of pain

Conservative management of nonspecific back pain and analgesia [2][3][4][5][66]

Conservative management is the preferred, first-line management of nonspecific LBP.
When analgesics are required, nonselective NSAIDs are preferred.
In older adults, avoid skeletal muscle relaxants and use NSAIDs with caution because of the risk of adverse effects; see “Principles of pharmacotherapy for older adults.” [5]
Glucocorticoids and back traction are not recommended for the treatment of back pain. [2][66]

Acute and subacute LBP

Assess for
risk factors for chronic back pain, which include:
[2][3][7][68]

Severe pain and functional impairment [2]

Psychosocial and workplace factors [2][69][70]

Previous episodes of LBP [2]

Use of non-evidence-based management [68]
Patients at low risk for
chronic back pain:
[68]
- Initial conservative management
  
  Superficial heat and/or massage
  
  Spinal manipulation
  
  Acupuncture
- Pain management
  
  Preferred: nonselective NSAIDs (e.g., ibuprofen , naproxen ) [2][5][71][72]
  
  Alternatives: Consider a short-term (< 3 weeks) nonbenzodiazepine muscle relaxant, e.g., cyclobenzaprine. [3][5]
Patients with risk factors for chronic back pain: Consider more intensive initial multidisciplinary rehabilitation. [3][7]

Patients with risk factors for chronic back pain are likely to benefit from early multidisciplinary rehabilitation rather than reassurance and patient education alone. [7][68]

Chronic LBP or patients at high risk for chronic LBP

Initial
conservative management
[3]
- Behavioral therapy
- Structured exercise programs
- Mobility assistive devices if needed
- Consider adjunctive therapies. [2][5][66]
Pain management
- Preferred: nonselective NSAIDs (e.g., ibuprofen , naproxen ) [2][5][71][72]
- Alternative: Consider short-term (< 3 months) topical capsicum. [2][66]
- Avoid
  routine use of:
  - Adjuvant analgesics (e.g., skeletal muscle relaxants, antidepressants) [2][3][5][66][73]
  - Opioids (see “Opioids for chronic noncancer pain”) [2][5][66]

Interventional therapy [2][4][74]

Interventional therapy is rarely required for nonspecific LBP; Refer patients with refractory disabling LBP to specialists (e.g., spine surgeons) for consideration of interventional management.
Possible benefit: radiofrequency ablation
Limited evidence of benefit: epidural steroid injections, spinal cord stimulation, surgery (e.g., discectomy, SI joint fusion)

Regular exercise combined with patient education (e.g., on posture, safe techniques for lifting and handling, and muscle strengthening) are effective preventive measures for back pain. [75][76][77]

Traumatic back pain

Etiology

Major trauma: e.g., motor vehicle accidents, direct high-impact injuries, fall from a height in a young, otherwise healthy individual
Minor trauma in individuals at risk of fragility fractures: low-impact injuries, such as a minor fall or lifting heavy weights

Management of traumatic back pain

Polytrauma patients: See “Management of trauma patients.”
Spinal immobilization if the likelihood of unstable vertebral fracture or spinal cord compression is high
Administer analgesics (preferably NSAIDs) after baseline neurological function and pain severity are documented (see “Pain management”).
Obtain urgent spinal surgery or neurosurgery consult in patients with new or progressive neurological abnormalities.
Obtain imaging.
[78]
- Preferred initial imaging modality: CT thoracic and lumbar spine without IV contrast .
- Thoracolumbar injury detected on CT:
  - MRI thoracic and lumbar spine without IV contrast
  - Alternatively, CT myelogram to identify spinal cord compression or injury (see “Urgent spinal causes of back pain”)
Further management depends on imaging findings

Consider imaging the entire spine, as injuries may occur at multiple levels.

Complications

Vertebral fractures
Intervertebral disc prolapse
Spinal epidural hematoma
Acute spinal cord compression (due to any of the above causes)
Soft tissue injury

**Vertebral compression fractures**
X-ray lumbar spine (lateral view)
There is marked compression of the L3 vertebral body (green overlay). Additional radiographic findings include diffuse osteopenia, multiple endplate compression deformities (examples indicated by dashed lines), and extensive atherosclerotic calcification of the abdominal aorta (A) and iliac arteries.

Our great thanks to Dr. Kissig (Center for Diagnostic and Interventional Radiology, Hedwigshöhe, St. Hedwig, Berlin, and St. Josefs Hospital, Potsdam) for kindly providing this image. Further notes: -mirrored

External Resources

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