Differential diagnosis

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Neck Back Extremities Floppy infant syndrome. Differential diagnosis. II. Back pain. requires careful evaluation if lasts more than 1 to 2 weeks (in child) usually the result of a serious underlying disorder including psychogenic back pain which is often difficult to manage. II. Back pain. - PowerPoint PPT Presentation

Text of Differential diagnosis

  • Differential diagnosisNeckBackExtremitiesFloppy infant syndrome

  • II. Back painrequires careful evaluation if lasts more than 1 to 2 weeks (in child)usually the result of a serious underlying disorder including psychogenic back pain which is often difficult to manage

  • II. Back painin the past, unlike adults, children were thought to uncommonly have back pain related to psychogenic causeschildren with acute or short-lived back pain: more likely to have muscle and ligamentous strain or pain associated with systemic viral infection

  • II. Back painHistory should include:locationdurationradiationcharacter of painillness or activity preceding its onsetInterference with normal daily & recreational activities should be determined

  • II. Back painExamination should seek other signs such as :abnormalities in gaitconfiguration of the back (subtle changes in contour may offer localizing clues)tenderness on palpation

  • II. Back painSkin overlying spine should be carefully inspected for:dimplestufts of hairhemangiomasother cutaneous changesAny cutaneous changes may denote developmental defects

  • II. Back painLesions causing back pain may also produce neurologic changes in extremities or bladder or bowel dysfunctionSigns of neuromuscular disease should also be sought

  • II. Back pain Most common causesHyperlordotic mechanical back painLigamentous or muscle strainSpondylolisthesisMyalgiasPsychogenicSpondylolysisScheuermann disease

  • II. Back pain Causes not to forgetHerniated discSpinal dysraphismUrinary tract infectionSpinal cord tumorsDiskitis

  • II. Back painLordotic mechanical back pain Reputed to be a common cause in adolescent athletesPain:only in lumbar areavariable hyperextension or hyperflexion testinginability to fully flex the spine forwardTrauma

  • II. Back painLordotic mechanical back pain Kyphosis of thoracic spine present in compensation for decreased forward mobility of lumbar spineSome have suggested contractures at the facet joints as site of painTrauma

  • II. Back painLigamentous or muscle strain History of fall, unusual exercise or other forms of trauma should be soughtThere may be localized tenderness and paravertebral muscle spasmStrain probably the most common cause of back pain but it should be short-livedTrauma

  • II. Back painProlapse of intervertebral discUncommon lesion in childrenAlmost always a history of injuryLower lumbar area usually involvedPain may be local or radiate to the legsAbnormal straight-leg-raising test most common physical findingTrauma

  • II. Back painSlipped vertebral apophysisMay occur after strenuous activity or heavy liftingSigns of a herniated discA small bone fragment, edge of ring apophysis, may be seen within spinal canal on imaging studiesLower lumbar spine most common siteTrauma

  • II. Back painMyalgias Muscle pain may be associated with a multitude of viral and bacterial infectionsAches not limited to paravertebral musclesInfectionsUrinary tract infection Back pain may be the primary complaintA urine culture should be done

  • II. Back painReferred painOther infections must be considered in addition to urinary tract infections including:pneumoniaappendicitispancreatitischolecystitis InfectionsUrinary tract infection Back pain may be the primary complaintA urine culture should be done

  • II. Back painDiskitisAching pain in lower back radiates to flanks, abdomen and lower extremitiesYoung child may refuse to walkIllness may be associated with low-grade fever, irritability and lethargyLimited back motionInfections

  • II. Back painOsteomyelitis of vertebraLocalized tenderness present at a specific levelSpine held rigid because of muscle spasmSystemic signs often absentInfectionsIliac osteomyelitis, sacroiliac joint infectionFrequently confused with appendicitis or septic arthritis of hip

  • II. Back painTuberculosisLess common cause of back pain todayDull local pain present over involved vertebraeThere may be a localized swellingDestruction of vertebrae may cause pressure on spinal nervesStiff gaitBack held rigidInfections

  • II. Back painTuberculosisLess common cause of back pain todayDull local pain present over involved vertebraeThere may be a localized swellingDestruction of vertebrae may cause pressure on spinal nervesStiff gaitBack held rigidInfections

  • II. Back painSpinal epidural abscessGenerally exquisite pain and tenderness on palpation over the site of abscessRapidly developing signs of spinal cord dysfunction such as paraparesis, loss of bladder and bowel control and sensory changesInfections

  • II. Back painBrucellosis Small abscesses may develop in vertebraeGenerally associated with widespread lymphadenopathyInfectionsAcute transverse myelopathy Rare disorderPreceded by upper respiratory infectionBack pain may be an early signProgressive weakness develops in 2 or 2 days

  • II. Back painOsteoid osteoma Gradual onsetWorse at nightOften relieved by aspirinPalpation discloses localized tendernessRadiographs reveal a small translucent area with surrounding dense boneNeoplastic disorders Benign tumors

  • II. Back painBenign osteoblastoma Symptoms similar to those of osteoid osteoma, but larger lesion and less adjacent bone density seen on radiograph filmsNeoplastic disorders Benign tumorsEosinophilic granuloma Usually only one vertebra involved with collapseIntervertebral disc spaces maintainedCondition may be asymptomaticMay be backache and postural change

  • II. Back painAneurysmal bone cyst Cystic expansile lesion in a vertebra may cause neurologic symptomsNeoplastic disorders Benign tumorsNeuroenteric cysts Signs of cord dysfunction present

  • II. Back painSpinal cord tumors Symptoms may be subacute or chronicMost common: gliomas, neurofibromas, teratomas, lipomasDevelopmental defects may be associated with cutaneous changesSigns of cord compression with changes in gait, bladder and bowel dysfunction, localized tenderness and scoliosisDeformity of foot such as cavus or cavovarus frequent presenting complaintNeoplastic disorders Malignant tumors

  • II. Back painEwing sarcomaOsteogenic sarcomaNeoplastic disorders Malignant tumorsNeuroblastomaWilms tumorLeukemia and lymphomaPain not localized and may be fleetingRarely, spinal cord compression may occur producing typical signs of spinal cord tumorsNeoplastic disorders Metastatic tumors

  • II. Back painBone abnormalitiesScheuermann disease (vertebral osteochondrosis)Produces a round-back deformitySeveral vertebrae may be wedged anteriorlyPathophysiologic mechanism thought to be prolapse of nucleus pulposis into the vertebrae body, possibly due to osteoporosisPain common, usually located over the apex of kyphosis

  • II. Back painBone abnormalitiesSpondylolisthesis Pain caused by anterior displacement of vertebraeUsually L5 slides forward on S1Sciatica, increased lumbar lordosis and tight hamstrings often present

  • II. Back painBone abnormalitiesSpondylolisthesis Pain caused by anterior displacement of vertebraeUsually L5 slides forward on S1Sciatica, increased lumbar lordosis and tight hamstrings often present

  • II. Back painBone abnormalitiesSpondylolysis Defect in pars interarticularis without vertebral slippingProbably result of a stress fractureLow-back pain common, sometimes with radiation down the legPain increased by activity

  • II. Back painBone abnormalitiesOccult fracturesTrauma, sometimes minor, may result in fractures of pars interarticularis or the transverse or spinous processesMay not be seen on plain radiographs

  • II. Back painBone abnormalitiesOsteoporosisFractures most likely to occur in osteoporotic bones present in disorders such as Cushing synd., OI, homocystinuria, Turner synd., malabsorption and immobilizationIdiopathic juvenile osteoporosis:Onset between 8 and 14 years of ageSelf-limited

  • II. Back painBone abnormalitiesScoliosis Almost always a painless disorderWhen back pain present, underlying problem should be sought such as infection, diskitis or tumor

  • II. Back painPsychogenic painBack pain may be associated with reaction to stressful situationsShould always be considered if patients affect is inconsistent with symptoms or if findings are unexplainableCareful history must be obtainedPsychogenic causes as cause of back pain seem to be on the rise

  • II. Back painMiscellaneous causesSickle cell disease Painful crises may be associated with back painJuvenile rheumatoid arthritisOccasionally, cervical pain may be a presenting complaint

  • II. Back painMiscellaneous causesAnkylosing spondylitis Usually boysArthritis in hips or knees and loss of mobility of the back may be foundChronic hemolytic anemiasSigns of cord compression may result from extramedullary hematopoiesis in extradural space

  • II. Back painMiscellaneous causesCalcification of intervertebral discsLocalized back painLoss of mobility due to muscle spasmCause unknownFluffy calcification in the disc space on radiograph films may not appear for 1 to 2 weeks following onset of pain

  • II. Back painMiscellaneous causesSpinal dysraphismLesions such as fibrous bands, lipomas, etc., may cause a tethered cord => back pain in addition to neurologic findings in lower extremities and bladder problemsClues to underlying problem should be sought by close examination of the skin over spine for cutaneous abnormalities

  • II. Back painMiscellaneous causesDiastematomyelia Developmental defect causes a cleft in the cord by bone, cartilage or fibrous septumCutaneous abnormalities over affected area may be apparentLow-back pain aggrav