Robert F. McLain, M.D., a spine surgeon in the Spine and Orthopedic Institute at St. Vincent Charity Medical Center, recently published in The Spine Journal and Journal of Orthopaedic Surgery and Research about when back pain suggests something worse.

When Back Pain Suggests Something Worse

Back pain, whether it's low back pain, neck pain or pain up between the shoulder blades, affects so many of us (more than 85% of normal adults at some point in their lives) that that almost everyone has had an ache or pain that has made them worry. Since the common causes of back and neck pain are typically age-related wear-and-tear changes or minor injuries, 90% of people improve with simple supportive care - rest, anti-inflammatory medications, and physical therapy.  However, when pain persists, or presents in an unusual way, you may begin to worry that the pain is coming from something more serious.

While serious, unrecognized diseases are very uncommon causes of back pain, there are some disorders that can seriously impact your health if they aren't recognized early enough. These kinds of disorders almost always offer a few clear clues to their diagnosis, however. A careful history and physical examination, looking for specific signs and symptoms, and properly selected diagnostic studies, will allow your physicians to confidently rule out important underlying diseases.

There are a few warning signs you should recognize and bring to your doctor's attention:

Persistent and Unremitting Back Pain

Unremitting pain typically raises the same fear in patients and care-givers – a concern for cancer.  Back pain is the presenting symptom in most patients with cancer that has moved into the spine. Patients who already know they have a cancerous condition should alert their doctors to order specific imaging studies without delay.

Patients with spinal cancer usually experience a different kind of pain from that in common back and neck injuries. Ordinary back pain is usually related to activity, relieved by rest and is often associated with a recognized lifting or physical injury. It may seem to linger forever, but in reality, it typically begins to get better after about four to six weeks of rest.

Instead of getting better with rest, pain caused by a spinal tumor is persistent, progressively getting more intense over time, and is not relieved by rest. Pain may actually feel worse at night, and feel a bit better when you are up and around. Thoracic back pain may be associated with belt-like burning pain around the torso, and lower back pain may be accompanied by symptoms of pain or weakness in the legs similar to what we see in a disc herniation. 

You should already be on the lookout for warning signs of different types of cancer – fatigue, unintended weight loss, abnormal bleeding, previously unrecognized lumps or bumps, or any signs of blood – either coughed up, or in the urine or stool.  Women should see their doctor for any signs of nipple discharge or breast mass, atypical vaginal bleeding or change in bowel habits.

Since the most common cause of a spinal cancer is a metastasis from cancers of the lungs, breasts, prostate, kidneys, colon and thyroid, these organs should be thoroughly checked by your doctor when cancer is suspected.

Fevers, Chills and Weight-loss

Patients with a spinal infection usually have localized pain, worse when they are bearing weight or engaged in activity. Pain can be intense, and may be relieved only by laying down.  Fever, chills, headache and generalized illness are usually present, but even with advanced infection these symptoms may be subtle or overlooked for some time. If, however, you've noticed that you are losing weight, experiencing fatigue and have had fevers, chills or night sweats in addition to your back pain, you should bring this to the attention of your doctor. Severe pain may be caused by simply sitting up or changing positions.  If the vertebra is weakened by infection it may collapse, and a deformity may be detected. 

Spinal infections usually start somewhere else, and the most frequent causes are urinary tract infections, dental abscesses, pneumonia or any chronic wound.  Back pain that starts up while you are being treated for one of these problems deserves a careful look.

Neurological signs should be carefully sought.  Patients who initially complain of focal spine pain, followed by progressive radicular pain, weakness and incipient paralysis may have infection within the canal, with development of an epidural abscess.

Abdominal Discomfort Mimicking Back Pain

There are a number of disorders involving the abdominal organs that can produce back pain symptoms, and some of these disorders are quite serious. Although rare, they cannot be overlooked.

The most serious vascular disorder presenting as back pain is the abdominal aortic aneurysm. Patients are often difficult to diagnose early on, as initial symptoms may be subtle and non-specific. As the process gets worse, the pain becomes deep-seated and localized to the thoracic or thoracolumbar segments of the spine.  If your doctors have already said you have an aneurysm, then intense pain, undiminished by narcotics, should trigger you to go immediately to the emergency room.   

Back pain can be triggered by disorders of the gastrointestinal tract. Ulcers, especially those involving the posterior duodenal wall, may cause upper lumbar back pain. A "perforated" ulcer may trigger intense pain and spasm, as well as signs of generalized illness and an acute abdomen.

Any type of kidney disease may cause back pain referred to the upper lumbar (thoracolumbar) junction and flank. Kidney stones are a notorious cause of severe, incapacitating back pain. This kind of pain typically comes in waves, causing intense back spasms and pain for a few minutes, then easing off for a bit before coming back with a vengeance.  Pain like this is referred to as colic, and is typical for kidney stones, gall stones and kidney infections.

Back pain caused by intra-abdominal sources is not directly aggravated by activity, may be colicky or throbbing in nature, and may be aggravated by eating, the menstrual cycle, or abdominal pressure or palpation. Pain like this is unlikely to originate from a spinal problem.

The key to identifying any of these disorders is a proper abdominal exam – meaning your doctor will want to get you into a gown, down on an exam table and carefully assess you. A simple x-ray can reveal or exclude the cause in many cases, but an abdominal CT scan may be needed to further clarify the problem.

Back Pain after a Fall or Injury: Fractures

Osteoporotic fractures of the vertebral body are the most commonly encountered fractures among primary care doctors.  These fractures are not always a result of great trauma and can, in some cases, cause few early symptoms.

Any history of a fall, a lifting injury, a motor vehicle accident or any other trauma, when it is associated with immediate back pain, suggests a muscle or bone injury. If you are osteoporotic, this trauma may be minimal – a sneeze, fall from a chair, or slip and fall in the home. Localized pain over the spinal column – most commonly the thoracic spine – is suggestive enough of compression fracture that x-ray is warranted. 

Localized pain over the involved vertebral level is usually present. Even patients with healthy bone can experience a compression fracture if the injury is significant enough. If you fall off of a roof, for instance, and end up with severe back pain in the middle of your lumbar spine, there's a decent chance you could have a compression fracture, and you should get that x-rayed. Of course, please don't do that!

Your Doctor may want to Order Some Studies:

Diagnostic Studies: Depending on the most likely concern, your doctor may order any of a number of basic laboratory studies to detect anemia, inflammation, and elevated levels of proteins or markers in your system. Urinalysis may reveal blood, bacteria or reveal a renal stone.

In infections, specific tests can reveal the presence of infectious agents before the actual source is revealed.  A TB skin test should be placed, if you have traveled anywhere that that disease is common, or have simply been around someone who has had the disease.

X-rays and Imaging: Some problems are only visualized on x-rays when significant bone destruction has occurred. A bone scan may be necessary to identify fractures, infections or tumors in their earliest phase.  More often, MRI can screen the whole spine, and shows the soft tissue elements inside and outside the spinal column. 

However, among patients with a recent osteoporotic spine fracture, x-rays are the best way to quickly and accurately detect a new fracture and determine how much collapse has occurred.

Remember This:

Spinal disorders can be complex and challenging conditions to treat and can cause pain despite the best of efforts.  The serious causes of back and neck pain we talked about here are very uncommon, but because they require definitive and specific treatment, and because early diagnosis is important in every case, it's important for you to know what to look for.

Identifying and treating the most dangerous causes of back pain is a matter of careful medical evaluation – with a proper examination, appropriate labs and the right imaging studies.

The good news is, when they all prove normal – as they almost always do – your physician can confidently reassure you that no ominous disease has been overlooked, and that you can devote your full concentration to rehabilitation and recovery from back pain.