• Continuous pain (day and night) = neoplasia, especially malignancy or infection.
• The big primary malignancy is multiple myeloma.
• The big three metastases are from lung, breast and prostate.
• The other three metastases are from thyroid, kidney/adrenal and melanoma.
• Pain with standing/walking (relief with sitting) = spondylolisthesis.
• Pain (and stiffness) at rest, relief with activity = inflammation.
• In a young person with inflammation think of ankylosing spondylitis or Reiter's disease.
• Stiffness at rest, pain with or after activity, relief with rest = osteoarthritis.
• Pain provoked by activity, relief with rest = mechanical dysfunction.
• Pain in bed at early morning = inflammation, depression or malignancy/infection.
• Pain in periphery of limb = discogenic ^ radicular or vascular ^ claudication or spinal canal stenosis ^ claudication.
• Pain in calf (ascending) with walking = vascular claudication.
• Pain in buttock (descending) with walking = neurogenic claudication.
• One disc lesion = one nerve root (exception is L5-S1 disc).
• Two or more nerve roots—consider neoplasm.
• The rule of thumb for the lumbar nerve root lesions is L3 from L2-L3 disc, L4 from L3-L4, L5 from L4-L5 and S1 from L5-S1.
• A large disc protrusion can cause bladder symptoms, either incontinence or retention.
• A retroperitoneal bleed from anticoagulation therapy can give intense nerve root symptoms and signs.
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