Is there any underlying systemic disease or infection causing the pain?
“The good news is that the dreaded diseases we worry about–metastatic cancer, spinal osteomyelitis, epidural abscess–count for only about 1% of the patients with back pain,” Dr. Deyo said. He added that about 80% of patients with an underlying malignancy are over 50 and advised physicians to carefully evaluate any patient with a history of malignancy. “Systemic signs such as unexplained weight loss, lymphadenopathy or hematuria should also prompt further investigation,” he said. The optimal next steps are unclear, but the “lowly sedimentation rate is useful as a screening tool because of its sensitivity, and a plain X-ray can be useful, too.” Studies suggest that if the X-ray is normal and the sed rate is normal, the likelihood of underlying cancer is close to zero, he added. Most spinal infections are blood-borne from another site, he explained. Spine tenderness to percussion is a relatively sensitive finding for bacterial infection and a sed rate can be helpful. Patients with fever
