Evaluation of Neck and Back Pain

Most pain caused by mechanical spine disorders is caused by

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 Cervical Herniated Nucleus Pulposus Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus. The tear causes pain due to irritation of sensory nerves in the disk, and... read more , 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 Fibromyalgia Fibromyalgia is a common, incompletely understood nonarticular, noninflammatory disorder characterized by generalized aching (sometimes severe); widespread tenderness of muscles, areas around... read more , frequently includes neck and/or back pain.

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 Spinal Cord Compression Various lesions can compress the spinal cord, causing segmental sensory, motor, reflex, and sphincter deficits. Diagnosis is by MRI. Treatment is directed at relieving compression. (See also... read more 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 Spinal Epidural Abscess A spinal epidural abscess is an accumulation of pus in the epidural space that can mechanically compress the spinal cord. Diagnosis is by MRI or, if unavailable, myelography followed by CT.... read more 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.

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

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:

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

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 Urinary Retention Urinary retention is incomplete emptying of the bladder or cessation of urination. Urinary retention may be Acute Chronic Causes include impaired bladder contractility, bladder outlet obstruction... read more , constipation Constipation Constipation is difficult or infrequent passage of stool, hardness of stool, or a feeling of incomplete evacuation. (See also Constipation in Children.) No bodily function is more variable and... read more , and fecal incontinence Fecal Incontinence Fecal incontinence is involuntary defecation. Diagnosis is clinical. Treatment is a bowel management program and perineal exercises, but sometimes colostomy is needed. (See also Evaluation of... read more .

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 Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more ); 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 Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more , osteoarthritis Osteoarthritis (OA) Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy (osteophyte formation). Symptoms... read more , 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).

Temperature and general appearance are noted. When possible, patients should be dressed in a gown and observed as they move into the examination room, walk, balance on one leg, 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 Deep tendon reflexes (See also Introduction to the Neurologic Examination) Deep tendon (muscle stretch) reflex testing evaluates afferent nerves, synaptic connections within the spinal cord, motor nerves, and descending... read more 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 Sciatica Sciatica is pain along the sciatic nerve. It usually results from compression of lumbar nerve roots in the lower back. Common causes include intervertebral disk herniation, osteophytes, and... read more . 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 Cervical Herniated Nucleus Pulposus Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus. The tear causes pain due to irritation of sensory nerves in the disk, and... read more ; 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 Abdominal Aortic Aneurysms (AAA) Abdominal aortic diameter ≥ 3 cm typically constitutes an abdominal aortic aneurysm. The cause is multifactorial, but atherosclerosis is often involved. Most aneurysms grow slowly (~10%/year)... read more ). With a fist, clinicians percuss the costovertebral angle for tenderness, suggesting pyelonephritis Chronic Pyelonephritis Chronic pyelonephritis is continuing pyogenic infection of the kidney that occurs almost exclusively in patients with major anatomic abnormalities. Symptoms may be absent or may include fever... read more .

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 Physical Examination Most women, particularly those seeking general preventive care, require a complete history and physical examination as well as a gynecologic evaluation. Gynecologic evaluation may be necessary... read more is done.

Lower-extremity pulses are checked.

The following findings are of particular concern:

Although serious extraspinal disorders (eg, cancers, aortic aneurysms Abdominal Aortic Aneurysms (AAA) Abdominal aortic diameter ≥ 3 cm typically constitutes an abdominal aortic aneurysm. The cause is multifactorial, but atherosclerosis is often involved. Most aneurysms grow slowly (~10%/year)... read more , epidural abscesses, osteomyelitis Osteomyelitis Osteomyelitis is inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. Common symptoms are localized bone pain and tenderness with constitutional symptoms (in acute... read more ) 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 ).

Other findings are also helpful. Worsening of pain with flexion is consistent with intervertebral disk disease; worsening with extension suggests spinal stenosis Lumbar Spinal Stenosis Lumbar spinal stenosis is narrowing of the lumbar spinal canal causing compression of the nerve rootlets and nerve roots in the cauda equina before their exit from the foramina. It causes positional... read more or arthritis affecting the facet joints. Tenderness over certain specific trigger points suggests muscle pain caused by a spinal disorder. Generalized tenderness and nonlocalized allodynia suggests a central pain disorder.

Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial choice of analgesics. Rarely, opioids Opioid Analgesics Nonopioid and opioid analgesics are the main drugs used to treat pain. Antidepressants, antiseizure drugs, and other central nervous system (CNS)–active drugs may also be used for chronic or... read more 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.

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.

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.

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. Facet joint corticosteroid injection is sometimes used for nonradicular pain. 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.

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 Fibromyalgia Fibromyalgia is a common, incompletely understood nonarticular, noninflammatory disorder characterized by generalized aching (sometimes severe); widespread tenderness of muscles, areas around... read more ) in whom nocturnal cyclobenzaprine may improve quality of sleep and reduce pain.

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 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 Osteoarthritis (OA) Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy (osteophyte formation). Symptoms... read more , cervical stenosis Cervical Spinal Stenosis Cervical spinal stenosis is narrowing of the cervical spinal canal causing compression of the nerve roots before their exit from the foramina. It causes positional neck pain, symptoms of nerve... read more , or osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more .

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.