Diagnosis	Key clinical clues
Intrinsic spine
Compression fracture	History of trauma (unless osteoporotic), point tenderness at spine level, pain worsens with flexion, and while pulling up from a supine to sitting position and from a sitting to standing position
Herniated nucleus pulposus	Leg pain is greater than back pain and worsens when sitting; pain from L1-L3 nerve roots radiates to hip and/or anterior thigh, pain from L4-S1 nerve roots radiates to below the knee
Lumbar strain/sprain	Diffuse back pain with or without buttock pain, pain worsens with movement and improves with rest
Spinal stenosis	Leg pain is greater than back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral (foraminal stenosis) or bilateral (central or bilateral foraminal stenosis)
Spondylolisthesis	Leg pain is greater than back pain; pain worsens with standing and walking, and improves with rest or when the spine is flexed; pain may be unilateral or bilateral
Spondylolysis	Can cause back pain in adolescents, although it is unclear whether it causes back pain in adults; pain worsens with spine extension and activity
Spondylosis (degenerative disk or facet joint arthropathy)	Similar to lumbar strain; disk pain often worsens with flexion activity or sitting, facet pain often worsens with extension activity, standing, or walking
Systemic
Connective tissue disease	Multiple joint arthralgias, fever, weight loss, fatigue, spinous process tenderness, other joint tenderness
Inflammatory spondyloarthropathy	Intermittent pain at night, morning pain and stiffness, inability to reverse from lumbar lordosis to lumbar flexion
Malignancy	Pain worsens in prone position, spinous process tenderness, recent weight loss, fatigue
Vertebral diskitis/ osteomyelitis	Constant pain, spinous process tenderness, often no fever, normal complete blood count, elevated erythrocyte sedimentation rate and/ or C-reactive protein level
Referred
Abdominal aortic aneurysm	Abdominal discomfort, pulsatile abdominal mass
Gastrointestinal conditions: pancreatitis, peptic ulcer disease, cholecystitis	Abdominal discomfort, nausea\vomiting, symptoms often associated with eating
Herpes zoster	Unilateral dermatomal pain, often allodynia, vesicular rash
Pelvic conditions: endometriosis, pelvic inflammatory disease, prostatitis	Discomfort in lower abdomen, pelvis, or hip
Retroperitoneal conditions: renal colic, pyelonephritis	Costovertebral angle pain, abnormal urinalysis results, possible fever