What are the possible causes of right lumbar (lower right back) pain accompanied by dizziness and nausea?

Right Lower Back Pain with Lightheadedness and Nausea: Differential Diagnosis

Right lower back pain accompanied by lightheadedness and nausea requires immediate evaluation to exclude serious conditions including abdominal emergencies (pancreatitis, nephrolithiasis, aortic aneurysm), spinal infection, malignancy, or cardiovascular causes, before attributing symptoms to nonspecific musculoskeletal pain. 1

Critical Red Flag Conditions to Rule Out First

The combination of back pain with systemic symptoms (lightheadedness, nausea) suggests potential non-spinal pathology that requires urgent attention:

Abdominal and Retroperitoneal Emergencies

• Nephrolithiasis (kidney stones) commonly presents with right flank/lower back pain radiating anteriorly, accompanied by nausea and vomiting 1
• Pancreatitis can cause back pain with severe nausea and may present with lightheadedness from volume depletion 1
• Abdominal aortic aneurysm must be considered, particularly in patients >50 years with cardiovascular risk factors, as rupture causes back pain with hemodynamic instability 1

Cardiovascular Causes

• Worsened end-organ perfusion from heart failure or other cardiovascular conditions manifests as lightheadedness, nausea, and can include back pain from fluid accumulation or poor perfusion 1
• Lightheadedness and nausea may indicate orthostatic hypotension, arrhythmia, or decreased cardiac output 1

Spinal Infection

• Vertebral osteomyelitis or epidural abscess (0.01% prevalence) presents with fever, recent infection, IV drug use, or immunocompromised status, and can cause nausea from systemic illness 1, 2
• Requires urgent MRI with contrast and laboratory studies (CBC, ESR, CRP) 2

Malignancy

• Vertebral metastases (0.7% prevalence) should be suspected with history of cancer (positive likelihood ratio 14.7), unexplained weight loss, age >50, or failure to improve after 1 month 1, 3, 2
• Nausea may result from hypercalcemia or systemic disease burden 2

Musculoskeletal Causes (If Red Flags Excluded)

Nonspecific Mechanical Low Back Pain

• Accounts for >85% of low back pain presentations but typically does NOT cause lightheadedness or nausea unless pain is severe enough to trigger vasovagal response 1, 3
• Pain worsens with activity and improves with rest 4

Radiculopathy or Spinal Stenosis

• Herniated disc (4% prevalence) presents with sciatica, positive straight-leg raise, and dermatomal deficits 1, 3
• Spinal stenosis (3% prevalence) causes pseudoclaudication and bilateral leg symptoms 3
• Neither typically causes lightheadedness or nausea 1, 3

Immediate Diagnostic Approach

History Elements to Obtain

• Age >50 years, history of cancer, unexplained weight loss, failure to improve after 1 month (malignancy risk factors) 1, 3, 2
• Fever, recent infection, IV drug use, immunocompromised status (infection risk factors) 1, 2
• Urinary symptoms, hematuria (nephrolithiasis) 1
• Cardiovascular history, orthostatic symptoms (cardiac causes) 1
• Timing of lightheadedness (positional vs. constant) 1
• Character of nausea (associated with movement, eating, or constant) 1

Physical Examination Priorities

• Vital signs including orthostatic blood pressure to assess hemodynamic stability 1
• Abdominal examination for tenderness, pulsatile mass, costovertebral angle tenderness 1
• Neurologic examination for motor deficits, sensory changes, reflexes 1
• Cardiovascular examination for signs of heart failure or arrhythmia 1

Imaging and Laboratory Strategy

• Immediate imaging is NOT indicated for nonspecific low back pain without red flags 3, 2
• Urgent imaging IS indicated when red flags present: MRI with contrast for suspected infection/malignancy, CT for suspected nephrolithiasis or aortic pathology 2
• Laboratory studies (CBC, ESR, CRP, urinalysis) when infection, malignancy, or renal pathology suspected 2

Critical Pitfalls to Avoid

• Attributing systemic symptoms to musculoskeletal pain without excluding serious abdominal, cardiovascular, or systemic pathology 1
• Delaying imaging when red flags present - immediate MRI indicated rather than the usual 4-6 week waiting period for nonspecific pain 2
• Missing cancer in patients with prior malignancy - posttest probability jumps from 0.7% to 9% in this population 3, 2, 4
• Overlooking cardiovascular causes - lightheadedness with nausea may indicate end-organ hypoperfusion requiring urgent cardiac evaluation 1