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Evaluation of Neck and Back Pain

by Sally Pullman-Mooar, MD

Neck pain and back pain are among the most common reasons for physician visits. This discussion covers neck pain involving the posterior neck (not pain limited to the anterior neck) and does not cover most major traumatic injuries (eg, fractures, dislocations, subluxations).

Pathophysiology

Depending on the cause, neck or back pain may be accompanied by neurologic symptoms.

If a nerve root is affected, pain may radiate distally along the distribution of that root (called radicular pain or, in the low back, sciatica). Strength, sensation, and reflexes of the area innervated by that root may be impaired.

Symptoms of Common Radiculopathies by Cord Level

Level

Symptoms

C6

Pain in the trapezius ridge and tip of the shoulder, often radiating to the thumb, with paresthesias and sensory impairment in the same areas

Weakness of biceps

Decreased biceps brachii and brachioradialis reflexes

C7

Pain in the shoulder blade and axilla, radiating to the middle finger

Weakness of triceps

Decreased triceps brachii reflex

T (any)

Bandlike dysesthesias around the thorax

L5

Pain in the buttock, posterior lateral thigh, calf, and foot

Footdrop with weakness of the anterior tibial, posterior tibial, and peroneal muscles

Sensory loss over the shin and dorsal foot

S1

Pain along the posterior aspect of the leg and buttock

Weakness of the medial gastrocnemius muscle with impaired ankle plantar flexion

Loss of ankle jerk

Sensory loss over the lateral calf and foot

If the spinal cord is affected, strength, sensation, and reflexes may be impaired at the affected spinal cord level and all levels below (called segmental neurologic deficits).

If the cauda equina is affected, segmental deficits develop in the lumbosacral region, typically with loss of bowel and bladder function, loss of perianal sensation, erectile dysfunction, urinary retention, and loss of rectal tone and sphincter (eg, bulbocavernosus, anal wink) reflexes.

Any painful disorder of the spine may also cause reflex tightening (spasm) of paraspinal muscles, which can be excruciating.

Etiology

Most neck and back pain is caused by disorders of the spine. Fibromyalgia (see Fibromyalgia) is also a common cause and may be superimposed on a chronic primary spinal disorder. Occasionally, pain is referred from extraspinal disorders (particularly vascular, GI, or GU disorders). Some uncommon causes—spinal and extraspinal—are serious.

Most spinal disorders are mechanical. Only a few involve infection, inflammation, or cancer (considered nonmechanical).

Common causes

Most mechanical spine disorders that cause neck or back pain involve a nonspecific mechanical derangement:

  • Muscle strain, ligament sprain, spasm, or a combination

Only about 15% involve specific structural lesions that clearly cause the symptoms, primarily the following:

  • Disk herniation

  • Compression fracture

  • Lumbar spinal stenosis

  • Osteoarthritis

  • Spondylolisthesis

In the other mechanical disorders, there are no specific lesions, or the findings (eg, disk bulging or degeneration, osteophytes, spondylolysis, congenital facet abnormalities) are common among people without neck or back pain, and thus are questionable as the etiology of pain. However, etiology of back pain, particularly if mechanical, is often multifactorial, with an underlying disorder exacerbated by fatigue, physical deconditioning, and sometimes psychosocial stress or psychiatric abnormality. Thus, identifying a single cause is often difficult or impossible. Neck and back pain are sometimes attributed to myofascial pain syndrome (see Myofascial Pain Syndrome); however, some experts consider that syndrome to be part of another disorder (such as fibromyalgia) rather than a primary disorder.

Serious uncommon causes

Serious causes may require timely treatment to prevent disability or death.

Serious extraspinal disorders include the following:

  • Abdominal aortic aneurysm

  • Aortic dissection

  • Carotid or vertebral artery dissection

  • Acute meningitis

  • Angina or MI

  • Certain GI disorders (eg, cholecystitis, diverticulitis, diverticular abscess, pancreatitis, penetrating peptic ulcer, retrocecal appendicitis)

  • Certain pelvic disorders (eg, ectopic pregnancy, ovarian cancer, salpingitis)

  • Certain pulmonary disorders (eg, pleuritis, pneumonia)

  • Certain urinary tract disorders (eg, prostatitis, pyelonephritis, nephrolithiasis)

Serious spinal disorders include the following:

  • Infections (eg, diskitis, epidural abscess, osteomyelitis)

  • Primary tumors (of spinal cord or vertebrae)

  • Metastatic vertebral tumors (most often from breasts, lungs, or prostate)

Mechanical spine disorders can be serious if they compress the spinal nerve roots or, particularly, the spinal cord. Spinal cord compression may result from disorders such as tumors and spinal epidural abscess or hematoma.

Other uncommon causes

Neck or back pain can result from many other disorders, such as Paget disease of bone, torticollis, thoracic outlet syndrome, temporomandibular joint syndrome, herpes zoster, retroperitoneal fibrosis, and spondyloarthropathies (ankylosing spondylitis most often, but also enteropathic arthritis, psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthropathy).

Evaluation

General

Because the cause is often multifactorial, a definitive diagnosis cannot be established in many patients. However, clinicians should determine the following if possible:

  • Whether pain has a spinal or extraspinal cause

  • Whether the cause is a serious disorder

History

History of present illness should include quality, onset, duration, severity, location, radiation, and time course of pain, as well as modifying factors such as rest, activity, changes in position, weight bearing, and time of day (eg, at night, when awakening). Accompanying symptoms to note include stiffness, numbness, paresthesias, weakness, urinary retention, and incontinence.

Review of systems should note symptoms suggesting a cause, including fever, sweats, and chills (infection); weight loss and poor appetite (infection or cancer); fatigue, depressive symptoms, and headaches (multifactorial mechanical back pain); worsening of neck pain during swallowing (esophageal disorders); anorexia, nausea, vomiting, and change in bowel function or stool (GI disorders); urinary symptoms and flank pain (urinary tract disorders), especially if intermittent, colicky, and recurrent (nephrolithiasis); cough, dyspnea, and worsening during inspiration (pulmonary disorders); vaginal bleeding or discharge and pain related to menstrual cycle phase (pelvic disorders).

Past medical history includes known neck or back disorders (including osteoporosis, osteoarthritis, disk disorders, and recent or remote injury) and surgery, risk factors for back disorders (eg, cancer, osteoporosis), risk factors for aneurysm (eg, smoking, hypertension), and risk factors for infection (eg, immunosuppression; IV drug use; recent surgery, penetrating trauma, or bacterial infection).

Physical examination

Temperature and general appearance are noted. When possible, patients should be unobtrusively observed as they move into the examination room, undress, and climb onto the table. If symptoms are exacerbated by psychologic issues, true functional level can be assessed more accurately when patients are not aware they are being evaluated.

The examination focuses on the spine and the neurologic examination. If no mechanical spinal source of pain is obvious, patients are checked for sources of referred pain.

In the spinal examination, the back and neck are inspected for any visible deformity, area of erythema, or vesicular rash. The spine and paravertebral muscles are palpated for tenderness, muscle spasm, and features of myofascial pain syndrome (taut bands, trigger points, and pressure sensitivity). Gross range of motion is tested.

The neurologic examination should at least assess function of the entire spinal cord. Strength and deep tendon reflexes are tested. In patients with neurologic symptoms, sensation and sacral nerve function (eg, rectal tone, anal wink reflex, bulbocavernosus reflex) are tested. Reflex tests are among the most reliable physical tests for confirming normal spinal cord function. Corticospinal tract dysfunction is indicated by the extensor plantar response and Hoffman’s sign. To test for Hoffman’s sign, clinicians tap the nail or flick the volar surface of the 3rd finger; if the distal phalanx of the thumb flexes, the test is positive, usually indicating corticospinal tract dysfunction caused by stenosis of the cervical cord. Sensory findings are subjective and may be unreliable.

The straight leg raise test helps confirm sciatica. The patient is supine with both knees extended and the ankles dorsiflexed. The clinician slowly raises the affected leg, keeping the knee extended. If sciatica is present, 10 to 60° of elevation typically causes symptoms. For the crossed straight leg raise test, the unaffected leg is raised; the test is positive if sciatica occurs in the affected leg. A positive straight leg test is sensitive but not specific for herniated disk; the crossed straight leg raise test is less sensitive but 90% specific. The seated straight leg raise test is done while patients are seated with the hip joint flexed at 90°; the lower leg is slowly raised until the knee is fully extended. If sciatica is present, the pain in the spine (and often the radicular symptoms) occurs as the leg is extended.

In the general examination, the lungs are auscultated. The abdomen is checked for tenderness, masses, and, particularly in patients > 55, a pulsatile mass (which suggests abdominal aortic aneurysm). With a fist, clinicians percuss the costovertebral angle for tenderness, suggesting pyelonephritis.

Rectal examination, including stool testing for occult blood and, in men, prostate examination, is done. In women with symptoms suggesting a pelvic disorder or with unexplained fever, pelvic examination is done.

Lower-extremity pulses are checked.

Red flags

The following findings are of particular concern:

  • Abdominal aorta that is > 5 cm (particularly if tender) or lower-extremity pulse deficits

  • Acute, tearing midback pain

  • Cancer, diagnosed or suspected

  • Duration of pain > 6 wk

  • Neurologic deficit

  • Fever

  • GI findings such as localized abdominal tenderness, peritonitis, melena, or hematochezia

  • Infection risk factors (eg, immunosuppression; IV drug use; recent surgery, penetrating trauma, or bacterial infection)

  • Meningismus

  • Severe nocturnal or disabling pain

  • Unexplained, new-onset pain after age 55

  • Unexplained weight loss

Interpretation of findings

Although serious extraspinal disorders (eg, cancers, aortic aneurysms, epidural abscesses, osteomyelitis) are uncommon causes of back pain, they are not rare, particularly in high-risk groups.

A spinal cause is more likely (but not definitive) than referred pain from an extraspinal cause when

  • Pain is worsened by movement or weight bearing and is relieved by rest or recumbency

  • Vertebral or paravertebral tenderness is present

Red flag findings should heighten suspicion of a serious cause (see Interpretation of Red Flag Findings in Patients With Back Pain).

Interpretation of Red Flag Findings in Patients With Back Pain

Finding

Causes to Consider

Abdominal aorta that is > 5 cm (particularly if tender) or lower-extremity pulse deficits

Abdominal aortic aneurysm

Acute, tearing midback pain

Thoracic aortic dissection

Cancer, diagnosed or suspected

Metastases

Duration of pain > 6 wk

Cancer

Subacute infection

Fever

Cancer

Infection

GI findings such as localized abdominal tenderness, peritonitis (rebound tenderness or abdominal rigidity), melena, or hematochezia

Possible GI emergency (eg, peritonitis, abscess, GI bleeding)

Infection risk factors

Infection

Meningismus

Meningitis

Neurologic deficit

Spinal cord or nerve root compression

Severe nocturnal or disabling pain

Cancer

Infection

Unexplained pain after age 55

Abdominal aortic aneurysm

Cancer

Unexplained weight loss

Cancer

Subacute infection

Other findings are also helpful. Erythema and tenderness over the spine suggest infection, particularly in patients with risk factors. Worsening of pain with flexion is consistent with intervertebral disk disease; worsening with extension suggests spinal stenosis, arthritis affecting the facet joints, or retroperitoneal inflammation or infiltration (eg, pancreatic or kidney inflammation or tumor). Tenderness over certain specific trigger points suggests fibromyalgia. Deformities of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) finger joints and stiffness that lessens within 30 min after awakening suggest osteoarthritis. Neck pain that is unrelated to swallowing and is exertional may indicate angina.

Testing

Usually, if duration of pain is short (< 4 to 6 wk), no testing is required unless red flag findings are present, patients have had a serious injury (eg, vehicular crash, fall from a height, penetrating trauma), or evaluation suggests a specific nonmechanical cause (eg, pyelonephritis).

Plain x-rays can identify most osteoporotic fractures and osteoarthritis. However, they do not identify abnormalities in soft tissue (the most common cause of back and neck pain) or nerve tissue (as occurs in many serious disorders). Thus, x-rays are usually unnecessary and do not change management. Sometimes x-rays are done to identify obvious bone abnormalities (eg, those due to infection or tumors) and to avoid MRI and CT, which are harder to obtain but which are much more accurate and usually necessary.

Testing is guided by findings and suspected cause:

  • Neurologic deficits, particularly those consistent with spinal cord compression: MRI or CT myelography, done as soon as possible

  • Possible infection: WBC count, ESR, imaging (usually MRI or CT), and culture of infected tissue

  • Possible cancer: CT or MRI and possibly biopsy

  • Possible aneurysm: CT, angiography, or sometimes ultrasonography

  • Possible aortic dissection: Angiography, CT, or MRI

  • Symptoms that are disabling or that persist > 6 wk: Imaging (usually MRI or CT) and, if infection is suspected, WBC count and ESR (some clinicians begin with anteroposterior and lateral x-rays of the spine to help localize and sometimes diagnose abnormalities)

  • Other extraspinal disorders: Testing as appropriate (eg, chest x-ray for pulmonary disorders, urinalysis for urinary tract disorders or for back pain with no clear mechanical cause)

Treatment

Underlying disorders are treated.

Acute musculoskeletal pain (with or without radiculopathy) is treated with

  • Analgesics

  • Heat and cold

  • Early mobilization followed by stabilization exercises

Acetaminophen or NSAIDs are the initial choice of analgesics, but opioids may be necessary for severe pain. Adequate analgesia is important immediately after acute injury to help limit the cycle of pain and spasm.

Acute muscle spasms may also be relieved by cold or heat. Cold is usually preferred to heat during the first 2 days after an injury. Ice and cold packs should not be applied directly to the skin. They should be enclosed (eg, in plastic) and placed over a towel or cloth. The ice is removed after 20 min, then later reapplied for 20 min over a period of 60 to 90 min. This process can be repeated several times during the first 24 h. Heat, using a heating pad, can be applied for the same periods of time. Because the skin on the back may be insensitive to heat, heating pads must be used cautiously to prevent burns. Patients are advised not to use a heating pad at bedtime to avoid prolonged exposure due to falling asleep with the pad still on their back. Diathermy may help reduce muscle spasm and pain after the acute stage.

Oral muscle relaxants (eg, cyclobenzaprine, methocarbamol, metaxalone) are controversial. Benefits of these drugs should be weighed against their CNS effects and other adverse effects, particularly in elderly patients, who may have more severe adverse effects.

Although a brief initial period (eg, 1 to 2 days) of decreased activity is sometimes needed for comfort, prolonged bed rest, spinal traction, and corsets are not beneficial. Patients with torticollis and sometimes cervical strains may benefit from a cervical collar and contour pillow until pain is relieved and they can participate in a stabilization program.

Spinal manipulation may help relieve pain caused by muscle spasm or an acute neck or back injury; however, some forms of manipulation may have risks for patients with disk disorders or osteoporosis.

When acute pain decreases enough that motion is possible, a lumbar stabilization program is begun. This program includes exercises that strengthen abdominal and low back muscles plus instruction in work posture; the aim is to strengthen the supporting structures of the back and reduce the likelihood of the condition becoming chronic or recurrent.

Clinicians should reassure patients with acute nonspecific musculoskeletal back pain that the prognosis is good and that activity and exercise are safe even when they cause some discomfort. Clinicians should be thorough, kind, firm, and nonjudgmental. If depression or secondary gain persists for several months, psychologic evaluation should be considered.

Geriatrics Essentials

Low back pain affects 50% of adults > 60.

Abdominal aortic aneurysm (and CT or ultrasonography to detect it) should be considered in older patients with atraumatic low back pain, particularly those who smoke or have hypertension, even if no physical findings suggest this diagnosis.

Imaging of the spine may be appropriate for elderly patients (eg, to rule out cancer) even when the cause appears to be uncomplicated musculoskeletal back pain.

Oral muscle relaxants (eg, cyclobenzaprine, methocarbamol, metaxalone) are controversial; anticholinergic, CNS, and other adverse effects may outweigh potential benefits in elderly patients.

Key Points

  • Most neck and back pain is caused by mechanical spinal disorders, usually nonspecific, self-limited musculoskeletal derangements.

  • Most mechanical disorders are treated with analgesics, early mobilization, and exercises; prolonged bed rest and immobilization are avoided.

  • Back pain is often multifactorial, making diagnosis difficult.

  • Serious spinal or extraspinal disorders are unusual causes.

  • Red flag findings often indicate a serious disorder and the need for testing.

  • Patients with segmental neurologic deficits suggesting spinal cord compression require MRI or CT myelography as soon as possible.

  • Normal spinal cord function during physical examination is best confirmed by tests of sacral nerve function (eg, rectal tone, anal wink reflex, bulbocavernosus reflex), knee and ankle jerk reflexes, and motor strength.

  • Pain not worsened by movement is often extraspinal, particularly if no vertebral or paravertebral tenderness is detected.

  • Abdominal aortic aneurysm should be considered in any elderly patient with low back pain that is not clearly mechanical, even if no physical findings suggest this diagnosis.

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