Differential Diagnosis for Lower Lumbar Pain

The patient presents with severe, throbbing, and unbearable lower lumbar pain that worsens with movement, without radiating pain, and has a recent history of potentially lifting something incorrectly at work. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Musculoskeletal Strain: Given the patient's occupation as a waitress, which involves frequent lifting and bending, and the recent incident of picking up something wrong, a musculoskeletal strain is the most plausible diagnosis. The symptoms of severe lower lumbar pain that progresses with movement align with this condition.

• Other Likely Diagnoses

  • Lumbar Disc Herniation: Although the patient denies radiating pain, lumbar disc herniation can initially present with localized back pain. The mechanism of injury (lifting something wrong) could have caused a disc herniation, which might not always have radicular symptoms initially.
  • Degenerative Disc Disease: This condition can cause chronic back pain, especially with movement, due to the degeneration of the intervertebral discs. The patient's occupation and recent incident could exacerbate underlying degenerative changes.
  • Spondylosis or Spondylolisthesis: These conditions involve defects in the pars interarticularis and can lead to back pain, especially with activity. The patient's recent lifting incident could have worsened a pre-existing condition.

• Do Not Miss Diagnoses

  • Cauda Equina Syndrome: Although rare and less likely given the absence of radiating pain, urinary retention, or saddle anesthesia, cauda equina syndrome is a medical emergency that requires immediate attention. It can be caused by a large disc herniation compressing the cauda equina.
  • Spinal Infection (Osteomyelitis, Discitis): Infections of the spine can present with severe back pain and are more common in individuals with certain risk factors (e.g., immunocompromised states). The absence of fever or other systemic symptoms does not rule out this diagnosis.
  • Spinal Fracture: Especially in individuals with osteoporosis or significant trauma, a spinal fracture could present with severe back pain. The patient's recent lifting incident might not seem significant enough for a fracture, but it should be considered, especially if there are underlying risk factors for osteoporosis.

• Rare Diagnoses

  • Spinal Tumor: Both primary and metastatic tumors can cause back pain, often constant and progressive. While rare, this diagnosis should be considered, especially if there are systemic symptoms (e.g., weight loss, fatigue) or if the pain does not improve with conservative management.
  • Aortic Aneurysm or Dissection: Abdominal aortic aneurysms can cause back pain, typically severe and tearing in nature. Although the patient's symptoms do not perfectly align with this condition, it is a critical diagnosis to consider due to its high mortality rate if ruptured.