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Chapter 9

Chapter 9. Differential Diagnosis. Overview. Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from those that are not

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Chapter 9

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  1. Chapter 9 Differential Diagnosis

  2. Overview • Differential diagnosis involves the ability to quickly differentiate those problems of a serious nature from those that are not • Problems of a serious nature include, but are not limited to visceral diseases, cancer, infections, fractures and vascular disorders

  3. Referred Pain • The term referred pain is used to describe those symptoms that have their origin at a site other than where the patient feels the pain

  4. Referred pain • Referred pain can be generated by: • Convergence of sensory input from separate parts of the body to the same dorsal horn neuron via primary sensory fibers • Secondary pain resulting from a myofascial trigger point • Sympathetic activity elicited by a spinal reflex • Pain-generating substances

  5. Referred Pain • Macnab recommends the following classification for referred pain: • Viscerogenic • Vasculogenic • Neurogenic • Psychogenic • Spondylogenic

  6. Viscerogenic Pain • Viscerogenic pain may be produced when the nociceptive fibers from the viscera, synapse in the spinal cord, with some of the same neurons that receive pain from the skin.

  7. Viscerogenic Pain • Visceral pain has five important clinical characteristics: • It is not evoked from all viscera • It is not always linked to visceral injury • It is diffuse and poorly localized • It is referred to other locations • It is accompanied with autonomic reflexes, such as the nausea, and vomiting

  8. Vasculogenic Pain • Vasculogenic pain tends to result from venous congestion or arterial deprivation to the musculoskeletal areas • Tends to mimic a wide variety of musculoskeletal, neurologic, and arthritic disorders, as this type of pain is often worsened by activity

  9. Neurogenic Pain • Neurogenic pain is pain that is referred from a neurological structure. • Neurogenic causes of pain may include: • A tumor compressing and irritating a neural structure of the spinal cord, meninges • A spinal nerve root irritation • Peripheral nerve entrapment • Neuritis

  10. Scanning Examination • The tests of the Cyriax upper or lower quarter scanning examination can be used to: • Examine the patient’s neurological status • Highlight the presence of a lesion to the central or peripheral nervous systems • Help rule out any serious pathology such as a fracture or tumor

  11. Scanning Examination • The upper quarter scanning examination is appropriate for upper thoracic, upper extremity, and cervical problems • The lower quarter scanning examination is typically used for thoracic, lower extremity, and lumbosacral problems

  12. Scanning Examination • The tests included in the scanning examination include strength testing, sensation testing (light touch and pin-prick), deep tendon reflexes, and the pathological reflexes

  13. Scanning Examination • At the end of each of the scanning examinations, either a medical diagnosis (disc protrusion, prolapse, or extrusion, acute arthritis, specific tendonitis, or muscle belly tear, spondylolisthesis or stenosis) can be made, or the scanning examination is considered negative

  14. Psychogenic Pain • Psychogenic (non-organic) pain is characterized by abnormal illness behaviors • Commonly exhibited by patient’s suffering from depression, emotional disturbance, or anxiety states • All patients should be given the benefit of the doubt until the clinician, with a high degree of confidence, can rule out an organic cause for the pain

  15. Spondylogenic Pain • Spondylogenic pain is pain referred from a vertebral lesion • Characteristics of a spondylogenic lesion include: • Severe and unrelenting pain • The presence of a fever • Bone tenderness • Unexplained weight loss

  16. Generalized Body Pain • Two conditions that can cause generalized body pain: • Fibromyalgia • Myofascial pain syndrome (MPS)

  17. Fibromyalgia • Poorly understood complex of generalized body aches that can cause pain or paresthesias, or both, in a non-radicular pattern • Not a disease, but rather a syndrome with a common set of characteristic symptoms, including widespread pain and the presence of a defined number of tender points

  18. Fibromyalgia • A positive tender point count of 11 or more of 18 standardized sites, when present in combination with the history of widespread pain, yields a sensitivity of 88.4% and a specificity of 81.1% in the diagnosis of fibromyalgia

  19. Myofascial Pain Syndrome • Characterized by the presence of myofascial trigger points (MTrPs) • A MTrP is a hyperirritable location, approximately 2 to 5 cm in diameter, [86]within a taut band of muscle fibers, that is painful when compressed and that can give rise to characteristic referred pain, tenderness, and tightness

  20. Causes of Head and Facial Pain • Trauma • Headaches • Migraine • Two types of migraine headaches: migraine without aura (common migraine), and migraine with aura • Migraine without aura: Symptoms are typically unilateral with a pulsating quality of moderate or severe intensity. Aggravated by routine physical activity, and is associated with nausea, auras, photophobia, and phonophobia • Migraine with aura: Characterized by reversible aura symptoms, which typically develop gradually over more than 4 minutes, but last no longer than 60 minutes

  21. Causes of Head and Facial Pain • Headaches • Cluster • Severe unilateral retro‑orbital headaches • Often accompanied by nasal congestion, eye-lid edema, rhinorrhea, miosis, lacrimation, and ptosis (drooping eyelid) on the symptomatic side • Patient’s feel better during a headache by remaining in an erect posture and moving about • Tension-type • Those associated with a disorder of the pericranial muscles, and those not associated with this type of disorder • Characterized by a bilateral non-throbbing ache in the frontal or temporal areas, and spasm, or hypertonus of the neck muscles

  22. Causes of Head and Facial Pain • Headaches • Benign exertional • Headache is specifically brought on by physical exercise, particularly with straining and valsalva type maneuvers such as those seen in weightlifting • Bilateral, throbbing in nature at onset and may develop migrainous features in those patients susceptible to migraine • Effort induced • Differ from the exertional headaches in that they are not necessarily associated with a power or straining type of exercise • Occur more frequently in hot weather

  23. Causes of Head and Facial Pain • Headaches • Occipital • Likely referred from a cervical disorder • The underlying musculoskeletal mechanism for this type of headache is often structural, including cervical hypomobility or hypermobility, joint subluxation, degenerative bony changes, or poor posture • Hypertensive • Occurs in individuals with diastolic readings above 120 mm Hg, although the intensity of these headaches does not necessarily parallel the height of the blood pressure levels

  24. Causes of Head and Facial Pain • Headaches • External compression headache • This entity, formerly known as ‘swim-goggle headache’, presents with pain in the facial and temporal areas produced from wearing excessively tight face masks or swimming goggles • Idiopathic carotidynia • Unilateral facial or orbital pain in half of the patients with this condition • Most commonly located in the frontotemporal area, but it occasionally involves the entire hemicranium or the occipital area • Chronic daily • Follows trauma to the head or neck

  25. Causes of Head and Facial Pain • Headaches • Post-traumatic • More prolonged and enduring headache than chronic daily • May be associated with subdural hematoma, an epidural hematoma, an intracerebral hematoma, an aneurysm, a subarachnoid hemorrhage or a cerebral contusion

  26. Causes of Head and Facial Pain • Occipital neuralgia • A rare neuralgic disorder involving the greater occipital nerve • Glossopharyngeal neuralgia • Characterized by intense unilateral attacks of pain in the retrolingual area radiating to the depth of the ear • The pain is typically aggravated by movement or contact with the pharynx, especially with swallowing

  27. Causes of Head and Facial Pain • Trigeminal neuralgia • Chronic pain syndrome characterized by dramatic, brief stabbing or electric shock-like pain paroxysms felt in one or more divisions of the trigeminal distribution, either spontaneously or on gentle tactile stimulation of a trigger point on the face or in the oral cavity • Bell’s palsy • A lower motor neuron disease of the facial nerve characterized by a wide range of facial muscle movement dysfunction from mild paresis to total paralysis

  28. Causes of Head and Facial Pain • Ramsay Hunt syndrome • A herpetic inflammation of the geniculate and/or facial nerve ganglia, manifests as a peripheral facial nerve palsy accompanied by an erythematous vesicular rash on the ear (zoster oticus) or in the mouth • Arteriovenous malformation • Congenital malformation

  29. Causes of Head and Facial Pain • Meningitis • An infection of the meninges and subarachnoid space • Classic triad of fever, neck stiffness, and an altered mental status • Cerebrovascular disease • Dependent on the size and location of the hemorrhage • Intracranial bleed • Dependent on the rate of arterial or venous bleeding

  30. Causes of Head and Facial Pain • Tumor • Tumors, benign or otherwise are space-occupying lesions that may increase to a size that compresses nearby structures or increases intracranial pressure • Encephalitis • An inflammation of the brain

  31. Causes of Head and Facial Pain • Systemic infections • Rocky Mountain Spotted Fever • Lyme disease • Pneumonia • Pyelonephritis • Multiple sclerosis • Optic neuritis

  32. Causes of Head and Facial Pain • Miscellaneous • Temporal arteritis • Acute sinusitis • Eclampsia • Cerebrospinal fluid (CSF) hypotension • Temporomandibular joint dysfunction • Peridontal disease • Thyroiditis • Fracture of the facial bones or skull • Trochleitis

  33. Causes of Cervical Pain • Thyroid disease • Widespread manifestations including cervical pain • Subarachnoid hemorrhage • Retropharyngeal abscess • Infection of the space anterior to the prevertebral layer of the deep cervical fascia • Carotodynia

  34. Causes of Cervical Pain • Cardiac disease • Trauma • Tumor • Tumors of the adult cervical spine may be primary, arising from the bone, or secondary • Temporomandibular Joint Dysfunction • Meningitis

  35. Causes of Cervical Pain • Cervical disk disease • Vertebral artery disorder • Torticollis • Rheumatoid arthritis • Cervical spine involvement is common in rheumatoid arthritis • Ankylosing spondylitis • Ankylosing spondylitis commonly affects the C 1-2 segment

  36. Causes of Cervical Pain • Gout • Although the occurrence of gout in the neck is distinctly uncommon, the medications used to treat it can have serious side-effects in this region • Osteoarthritis • Occipital neuralgia

  37. Causes of Thoracic Pain • Gastrointestinal conditions • Pancreatic carcinoma • Mediastinal tumors • Although primary tumors of the thoracic spine are rare, the thoracic spine is the most common site for metastases • Myocardial infarction • Pleuropulmonary conditions • Thoracic disk • Vertebral or rib fracture • Intercostal neuralgia

  38. Causes of Thoracic Pain • Epidemic myalgia • Costochondritis • Osteoarthritis • Rheumatoid arthritis • Ankylosing spondylitis • Diffuse Idiopathic Skeletal Hyperostosis (DISH) • Characterized by an ossification of the anterior longitudinal ligaments and all related, anatomically similar ligaments • Manubrium-sternal dislocations

  39. Causes of Lumbar Pain • Strain or sprain • Renal disorder • Epidural abscess • Prostatitis • Pleural dysfunction • Aortic aneurysm • Metastasis • Ankylosing spondylitis • Stiff-person syndrome

  40. Causes of Buttock and Upper and Lower Leg Pain • Lumbar disc herniation • Femoral nerve neuropathy • Piriformis syndrome • Sacral plexopathy • Intermittent claudication • Conus medullaris syndrome • Severe low back and buttock pain, lower limb weakness, saddle hypesthesia or anesthesia. Bowel and bladder changes are also frequently reported • Meralgia paresthetica

  41. Causes of Buttock and Upper and Lower Leg Pain • Iliofemoral thrombophlebitis • Mononeuritis multiplex • May occur in association with a number of other medical conditions including rheumatoid arthritis (RA), vasculitis, polyarteritis nodosa, diabetes mellitus, sarcoidosis, and amyloidosis • Ischial apophysitis and avulsion • Gluteal compartment syndrome • Genital herpes • Vascular Disorders

  42. Causes of Pelvic Pain • Sacroiliac arthritis • Acute appendicitis • Iliopsoas abscess • Iliopsoas hematoma • Sign of the buttock • Gynecologic disorders • Prostate cancer

  43. Causes of Trochanteric, Pubic, and Thigh pain • Dislocation and fracture dislocation of the hip • Labral tear • Hip or pelvis fracture • Pubic fracture • Femoral neck stress fracture • Osteoarthritis of the hip • Septic arthritis of the hip • Osteoid osteoma • Reiter’s syndrome

  44. Causes of Trochanteric, Pubic, and Thigh pain • Synovitis of the hip in children or adolescents • Avascular necrosis of the femoral head • Iliopsoas abscess • Iliofemoral venous thrombosis • Obturator, femoral or inguinal hernia • Osteomyelitis of the pubis

  45. Causes of Trochanteric, Pubic, and Thigh pain • Compartment syndrome • Myoneural anoxia results from a prolonged increase in tissue pressure within a closed osseofascial space. This compromises local blood flow of skeletal muscle, resulting in ischemia and necrosis • Sexually transmitted disease

  46. Causes of shoulder pain • Tendinous and capsular lesions • Traumatic synovitis • Subluxation/dislocation • Spondyloarthropy • Acute arthritis • Infections/tumors • Clay shoveler’s fracture • A traction fracture of the lower cervical or upper thoracic spine due to an excessive pull of the trapezius, rhomboid muscles during heavy work

  47. Causes of shoulder pain • Degenerative conditions • Vascular conditions • Metabolic conditions • Osseous lesions • Muscular lesions • Cerebrovascular disease • Multiple sclerosis • Amyotrophic lateral sclerosis • Guillian-Barre

  48. Causes of shoulder pain • Syringomyelia • Cervical radicular pain • Elbow dysfunction • Myofascial pain syndrome • Peripheral nerve entrapment

  49. Causes of shoulder pain • Brachial plexopathy • Herpes Zoster • Gallbladder dysfunction • Cardiac dysfunction • Pulmonary dysfunction • Visceral • Diaphragm • Spleen

  50. Causes of elbow and forearm pain • Fracture • Dislocation • Osteochondritis • Ligament sprain • Arthrosis • Peripheral nerve entrapment

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