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Intraspinal Hemorrhage Sudden, excruciating midline back pain (le coup de poignard or the strike of the dagger ) often with rapidly evolving paraparesis, urinary retention, and numbness of the legs may announce the occurrence of subarachnoid, subdural, or epidural bleeding The most common causes of such an event are a coagulopathy (mainly from warfarin) and a spinal arteriovenous malformation (AVM), as discussed on pages 1070 and 1072 Spinal arterial aneurysms are much less common underlying lesions It should be mentioned that back pain of comparable intensity may mark the onset of acute myelitis, spinal cord infarction, compression fracture, and occasionally, Guillain-Barre syndrome Pain from Visceral Disease Peptic ulcer disease and carcinoma of the stomach most typically induce pain in the epigastrium However, if the posterior stomach wall is involved, particularly if there is retroperitoneal extension, the pain may be felt in the thoracic spine, centrally or to one side, or in both locations If intense, it may seem to encircle the body The back pain tends to re ect the characteristics of the pain from the affected organ; eg, if due to peptic ulceration, it appears about 2 h after a meal and is relieved by food and antacids Diseases of the pancreas are apt to cause pain in the back, being more to the right of the spine if the head of the pancreas is involved and to the left if the body and tail are implicated Retroperitoneal neoplasms eg, lymphomas, renal cell tumors, sarcomas, and other carcinomas may evoke pain in the thoracic or lumbar spine with a tendency to radiate to the lower part of the abdomen, groins, anterior thighs, or ank A tumor in the iliopsoas region often produces a unilateral lumbar ache with radiation toward the groin and labia or testicle; there may also be signs of involvement of the upper lumbar spinal roots An aneurysm of the abdominal aorta may induce pain localized to an analogous region of the spine The sudden appearance of lumbar pain in a patient receiving anticoagulants should arouse suspicion of retroperitoneal bleeding This pain may also be referred to the groin In ammatory diseases and neoplasms of the colon cause pain that may be felt in the lower abdomen, the midlumbar region, or both As with intense pain higher in the spine, it may have a beltlike distribution Pain from a lesion in the transverse colon or rst part of the descending colon may be central or left-sided; its level of reference is to the second and third lumbar vertebrae If the sigmoid colon is implicated, the pain is lower, in the upper sacral spine and anteriorly in the suprapubic region or left lower quadrant of the abdomen Retroperitoneal appendicitis may have an odd referral of pain to the low ank and back Gynecologic disorders often manifest themselves by back pain, but their diagnosis is seldom dif cult Thorough abdominal palpation as well as vaginal and rectal examination by an experienced physician, supplemented by ultrasound and CT scanning or MRI, usually discloses the source of pain The uterosacral ligaments are the most important pelvic source of chronic back pain Endometriosis or carcinoma of the uterus (body or cervix) may invade these structures, causing pain localized to the sacrum either centrally or more to one side In endometriosis, the pain begins premenstrually and often merges with menstrual pain, which also may be felt in the sacral region Rarely, cyclic engorgement of ectopic endometrial tissue may give rise to sciatica and other radicular pain Malposition of the uterus (retroversion, uterus descensus, and prolapse) characteristically gives rise to sacral pain, especially after the patient has been standing for several hours Changes in posture may also evoke pain here when a broma of.

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the uterus pulls on the uterosacral ligaments Low back pain with radiation into one or both thighs is a common phenomenon during the last weeks of pregnancy Pain due to carcinomatous in ltration of pelvic nerve plexuses is continuous and becomes progressively more severe; it tends to be more intense at night and may have a burning quality The primary lesion can be inconspicuous and may be overlooked on pelvic examination Coccydynia This is the name applied to pain localized to the tail piece, the three or four small vestigial bones at the lowermost part of the sacrum The trauma of childbirth, a fall on the buttocks, avascular necrosis, a glomus tumor, or one of a variety of other rare tumors and anal disorders can sometimes be established as the cause of pain in this region Far more often, the source remains obscure In the past, patients in this latter group were indiscriminately subjected to coccygectomy, but more recent studies have demonstrated that most cases respond favorably to injections of local anesthetic and methylprednisolone or to manipulation of the coccyx under anesthesia (Wray et al) Obscure Types of Low Back Pain and the Question of Psychiatric Disease It is a safe clinical rule that most patients who complain of low back pain have some type of primary or secondary disease of the spine and its supporting structures or of the abdominal or pelvic viscera However, even after careful examination, there remains a sizable group of patients in whom no pathologic basis for the back pain can be found Two categories can be recognized: one with postural back pain and another with aggravating psychiatric illness, but there are always cases where the diagnosis remains obscure Postural Back Pain Many slender, asthenic individuals and some fat, middle-aged ones have chronic discomfort in the back, and the pain interferes with effective work The physical examination is unrevealing except for slack musculature and poor posture The pain is diffuse in the middle or lower region of the back; characteristically, it is relieved by bed rest and induced by the maintenance of a particular posture over a period of time Spinal manipulation is said to have helped a number of these patients Pain in the neck and between the shoulder blades is a common complaint among thin, tense, active women and seems to be related to taut trapezius muscles Adolescent girls and boys are subject to a form of epiphysial disease of the spinal vertebrae (Scheuermann disease), which, over a period of 2 to 3 years, may cause low back pain upon exercise Some of these individuals are predisposed to kyphoscoliosis Also in this age group, spondylolysis, described earlier in this chapter, should be excluded as a cause of persistent back pain Psychiatric Illness Low back pain may be a major symptom in patients with hysteria, malingering, anxiety neurosis, depression, and hypochondriasis as well as in many nervous persons whose symptoms do not conform to any of these psychiatric illnesses Again, it is good practice to assume that pain in the back in such patients may signify disease of the spine or adjacent structures, and this should always be carefully sought However, even when some organic factors are found, the pain may be exaggerated, prolonged, or woven into a pattern of invalidism because of coexistent primary or secondary psychologic factors This is especially true when there is the possibility of secondary gain (notably workers compensation or settlement of personal injury claims) Patients seeking compensation for protracted low back pain without obvious structural dis-.

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