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Evaluation of Neck and Back Pain

By

Peter J. Moley

, MD, Hospital for Special Surgery

Last full review/revision Nov 2020| Content last modified Nov 2020
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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 low back pain, but it 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 (radicular pain). Strength, sensation, and reflexes of the area innervated by that root may be impaired. (See How to Assess Reflexes.)

Table
icon

Symptoms of Common Radiculopathies by Dermatomal Level

Level

Symptoms

C4

Pain in the lower neck and trapezius area with paresthesias involving the lower neck and upper shoulder girdle

C5

Pain in neck, shoulder, and dorsal forearm with paresthesias and numbness involving the dorsal arm

Weakness of deltoid, biceps, rotator cuff

Decrease in the biceps reflex

C6

Pain in the trapezius ridge and tip of the shoulder, often radiating to the thumb and index finger, with paresthesias and numbness in the same areas

Weakness of the wrist extensors

Decreased brachioradialis reflexes

C7

Pain, paresthesias, and numbness in the shoulder blade and axilla, radiating to the long and ring fingers

Weakness of triceps

Decreased triceps brachii reflex

T (any)

Bandlike dysesthesias around the thorax (eg, T6 nipple and T10 umbilicus)

L3

Pain, numbness, and paresthesias in anterolateral thigh and knee with quadriceps weakness and diminished patellar reflex

L4

Pain, numbness, and paresthesias in posterolateral thigh and anterior leg, weakness of quadriceps and ankle dorsiflexion, and diminished patellar reflex

L5

Pain in the buttock, posterior lateral thigh, anterolateral leg, and dorsal foot

Footdrop with weakness of the extensor hallucis longus and anterior tibial, and peroneal muscles

Diminished hamstring reflex

Pain, numbness, and paresthesias over the shin and dorsal foot

S1

Pain along the posterior aspect of the thigh, leg, and buttock

Weakness of the gastrocnemius muscle with impaired ankle plantar flexion

Loss of the ankle jerk (Achilles reflex)

Numbness and paresthesias over the lateral aspects of the calf, ankle, 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 disruption of bowel function (constipation or fecal incontinence) and bladder function (urinary retention or urinary incontinence), loss of perianal sensation, erectile dysfunction, 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.

Etiology

Most neck and back pain is caused by disorders of spinal structures. Muscle pain is a common symptom and is typically caused by irritation of the deeper muscles by the dorsal rami of the spinal nerve and in the more superficial muscles from a local reaction to the spine injury. Strains are very rare in the cervical and lumbar spine. Fibromyalgia can coexist with neck and back pain but is not more likely to cause isolated pain in the neck or back. Occasionally, pain is referred from extraspinal disorders (particularly vascular, gastrointestinal, or genitourinary). Some uncommon causes—spinal and extraspinal—are serious.

Most spinal disorders result from

  • Mechanical problems

Only a few involve nonmechanical problems, such as infection, inflammation, cancer, or fragility fractures due to osteoporosis or cancer.

Common causes

Most pain caused by mechanical spine disorders is caused by

  • Disk pain

  • Nerve root pain

  • Arthritis of the joints

The following are the most common causes of neck and low back pain.

All of these disorders also can be present without causing pain.

Several anatomic abnormalities (eg, disk bulging or degeneration, osteophytes, spondylolysis, facet abnormalities) are commonly present in people without neck or back pain, and thus are questionable as the etiology of pain. However, the etiology of back pain, particularly if mechanical, is often multifactorial, with underlying disorders exacerbated by fatigue, physical deconditioning, muscle pain, poor posture, weakness of stabilizing muscles, decreased flexibility, and sometimes psychosocial stress or psychiatric abnormality. Thus, identifying a single cause is often difficult or impossible.

A generalized myofascial pain syndrome, such as fibromyalgia, frequently includes neck and/or back pain.

Serious uncommon causes

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

Serious extraspinal disorders include the following:

Serious spinal disorders include the following:

Mechanical spine disorders can be serious if they compress the spinal nerve roots or, particularly, the spinal cord. Spinal cord compression only occurs in the cervical, thoracic, and high lumbar spine and may result from severe spinal stenosis or disorders such as tumors and spinal epidural abscess or hematoma. Nerve compression commonly occurs at the level of a disk herniation paracentrally or in the foramen, centrally or in the lateral recess with stenosis, or in the foramen of an exiting nerve.

Other uncommon causes

Neck or back pain can result from many other disorders, such as

Evaluation

General

Because the cause of neck or back pain 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

If serious causes have been ruled out, back pain is sometimes classified as follows:

  • Nonspecific neck or low back pain

  • Neck or low back pain with radicular symptoms

  • Lumbar spinal stenosis with claudication (neurogenic) or cervical stenosis with myelopathy

  • Neck or low back pain associated with another spinal cause

History

History of present illness should include quality, onset, duration, severity, location, radiation, time course of pain, and alleviating and exacerbating 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 incontinence or retention, constipation, and fecal incontinence.

Review of systems should note symptoms suggesting a cause, including fever, sweats, and chills (infection); weight loss and poor appetite (infection or cancer); worsening of neck pain during swallowing (esophageal disorders); anorexia, nausea, vomiting, melena or hematochezia, and change in bowel function or stool (gastrointestinal 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); fatigue, depressive symptoms, and headaches (multifactorial mechanical neck or back pain).

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, cancers, including those of the breast, prostate, kidney, lung, and colon as well as leukemias), risk factors for aneurysm (eg, smoking, hypertension), risk factors for infection (eg, immunosuppression; IV drug use; recent surgery, hemodialysis, penetrating trauma, or bacterial infection); and extra-articular features of an underlying systemic disorder (eg, diarrhea or abdominal pain, uveitis, psoriasis).

Physical examination

Temperature and general appearance are noted. When possible, patients should be observed as they move into the examination room, undress, and climb onto the table to assess gait and balance.

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 localized or 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, and change in muscle tone. Gross range of motion is tested. In patients with neck pain, the shoulders are examined. In patients with low back pain, the hips are examined.

The neurologic examination should assess function of the entire spinal cord. Strength, sensation, and deep tendon reflexes are tested. Reflex tests are among the most reliable physical tests for confirming normal spinal cord function. Corticospinal tract dysfunction is indicated by upgoing great toes with the plantar response and by the Hoffman sign, most often with hyperreflexia.

To test for the Hoffman 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 or a brain lesion. 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. Although the knee is often palpated from behind to assess for sciatica, it is probably not a valid test for this.

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. The slump test is similar to the straight leg raise test in applying traction on spinal nerve roots but is done with the patient "slumping" (with the thoracic and lumbar spines flexed) and the neck flexed while the patient is seated. The slump test is more sensitive, but less specific, for disk herniation than the straight leg raise test.

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. Rectal tone and reflexes are assessed. 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 upper and midback pain

  • Cancer, diagnosed or suspected

  • Neurologic deficit

  • Fever or chills

  • Gastrointestinal findings such as localized abdominal tenderness, peritoneal signs, 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 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.

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

Table
icon

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

Acute, tearing upper and midback pain

Cancer, diagnosed or suspected

Metastases

Duration of pain > 6 weeks

Cancer

Subacute infection

Fever

Cancer

Infection

Gastrointestinal findings such as localized abdominal tenderness, peritoneal signs (rebound tenderness or abdominal rigidity), melena, or hematochezia

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

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

Infection

Meningismus

Neurologic deficit

Nerve root or spinal cord compression

Severe nocturnal or disabling pain

Cancer

Infection

Unexplained weight loss

Cancer

Subacute infection

Other findings are also helpful. Worsening of pain with flexion is consistent with intervertebral disk disease; worsening with extension suggests spinal stenosis or arthritis affecting the facet joints. Tenderness over certain specific trigger points suggests muscle pain caused by a spinal disorder.

Testing

Usually, if duration of pain is short (< 4 to 6 weeks), 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 disk height loss, anterior spondylolisthesis, malalignment, osteoporotic (or fragility) fractures, osteoarthritis, and other serious bone abnormalities (eg, those due to infection or tumors), and they may be helpful in deciding whether additional imaging studies such as MRI or CT are warranted. However, they do not identify abnormalities in soft tissue (the disks) or nerve tissue (as occurs in many serious disorders).

Testing is guided by findings and suspected cause. Testing is also indicated in patients who have failed initial treatment or in those whose symptoms have changed. Testing for specific suspected causes includes the following:

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

  • Possible infection: White blood cell (WBC) count, erythrocyte sedimentation rate (ESR), imaging (usually MRI or CT), and culture of infected tissue

  • Possible cancer: CT or MRI, complete blood count (CBC), 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 weeks: 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

  • Lumbar stabilization and exercise

  • Heat and cold

  • Activity modification and rest (up to 48 hours) as needed

  • Reassurance

In patients with acute nonspecific (nonradicular) neck or low back pain, treatment can be started without extensive evaluation to identify a specific etiology.

Pearls & Pitfalls

  • Treat patients with nonspecific, nonradicular back pain who have no red flag findings symptomatically, without first requiring testing.

Analgesics

Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial choice of analgesics. Rarely, opioids may be necessary, using appropriate precautions, for severe acute pain. Adequate analgesia is important immediately after acute injury to help limit the cycle of pain and spasm. Evidence of benefit for chronic use is weak or absent, so duration of opioid use should be limited.

Cervical and lumbar stabilization and exercise

When acute pain decreases enough that motion is possible, a cervical or lumbar stabilization program is begun under the supervision of a physical therapist. This program should be started as soon as practical and includes restoration of motion, exercises that strengthen paraspinal muscles, and 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. In low back pain, "core" (abdominal and low back) muscle strengthening is important and often begins with a progression from working on a table in a supine or prone position, to quadruped (on hands and knees), and finally to standing activities.

Heat and cold

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 minutes over a period of 60 to 90 minutes. This process can be repeated several times during the first 24 hours. 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.

Corticosteroids

In patients with severe radicular symptoms and lower back pain, some clinicians recommend a course of oral corticosteroids or early referral to a specialist for epidural injection therapy. However, evidence supporting the use of systemic and epidural corticosteroid use is controversial. If epidural corticosteroid injection is planned, clinicians should obtain an MRI before injection so that the pathology can be identified, localized, and optimally treated.

Muscle relaxants

Oral muscle relaxants (eg, cyclobenzaprine, methocarbamol, metaxalone, benzodiazepines) are controversial. Benefits of these drugs should be weighed against their central nervous system (CNS) effects and other adverse effects, particularly in older patients, who may have more severe adverse effects. Muscle relaxants should be restricted to patients with visible and palpable muscle spasm and used for no more than 72 hours, except in some patients with central pain syndrome (eg, fibromyalgia) in whom nocturnal cyclobenzaprine may facilitate sleep and reduce pain.

Rest and immobilization

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 cervical pain may benefit from a cervical collar and contour pillow until pain is relieved and they can participate in a stabilization program.

Spinal manipulation

Spinal manipulation may help relieve pain caused by muscle spasm or an acute neck or back injury; however, high-velocity manipulation may have risks for patients older than 55 (eg, vertebral artery injury with neck manipulation) and those with severe disk disorders, cervical arthritis, cervical stenosis, or osteoporosis.

Reassurance

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 persists for several months or secondary gain is suspected, 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 older patients (eg, to rule out cancer) even when the cause appears to be uncomplicated musculoskeletal back pain.

Use of oral muscle relaxants (eg, cyclobenzaprine, methocarbamol, metaxalone) and opioids is controversial; anticholinergic, central nervous system, and other adverse effects may outweigh potential benefits in older patients.

Key Points

  • Low back pain affects 50% of adults > 60.

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

  • Back pain is often multifactorial, making identification of a specific etiology difficult.

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

  • In patients with acute nonradicular back pain, treatment can be started without extensive evaluation to identify a specific etiology.

  • Although serious spinal or extraspinal disorders are unusual causes, red flag findings often indicate the need for testing.

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

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

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

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