Overview of Neck and Back Pain

Most pain caused by mechanical spine disorders is caused by

• Disc pain

• Nerve root pain

• Arthritis of the joints

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

• Disc herniation

• Compression fracture (usually thoracic or lumbar)

• Lumbar and cervical spinal stenosis

• Osteoarthritis throughout the spine

• Spondylolisthesis

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

Several anatomic abnormalities (eg, disc 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 mental health condition. Thus, identifying a single cause is often difficult or impossible, especially in the setting of chronic pain.

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

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 myocardial infarction

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

• Certain pelvic disorders (eg, ectopic pregnancy, ovarian cancer, salpingitis (see Pelvic Inflammatory Disease (PID))

• Certain pulmonary disorders (eg, pleuritis, pneumonia)

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

• Extraspinal cancer metastases

• Retroperitoneal inflammatory or infiltrative disorders (eg, retroperitoneal fibrosis, immunoglobulin G4-related disease [IgG4-RD], hematoma, adenopathy)

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 only occurs in the cervical, thoracic, and high lumbar spine and may result from severe spinal stenosis or disorders such as tumors, spinal epidural abscess, or hematoma. Nerve compression commonly occurs at the level of a disc herniation paracentrally or in the foramen of an exiting nerve.

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 (even before the rash)

• Spondyloarthropathies (ankylosing spondylitis, enteropathic arthritis, psoriatic arthritis, reactive arthritis, and undifferentiated spondyloarthropathy)

• Brachial or lumbar plexus injury or inflammation (eg, Parsonage Turner syndrome)

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 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, hematuria, 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, disc 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; injection illicit drug use; recent surgery, hemodialysis, penetrating trauma, or recent 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, to assess gait and balance, 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 examination table.

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.

How to Examine the Back

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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.

How to Examine the Neck

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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 in the hand, 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 lumbosacral radiculopathy. The patient is supine with both knees extended and the ankles dorsiflexed. The clinician slowly raises the affected leg, keeping the knee extended. If lumbosacral radiculopathy 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 lumbosacral radiculopathy occurs in the affected leg. A positive straight leg raise test is sensitive but not specific for herniated disc; the crossed straight leg raise test is less sensitive than the straight leg raise test but is 90% specific.

The seated straight leg raise test (slump 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 lumbosacral radiculopathy 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 disc 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.

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; injection illicit drug use; recent surgery, penetrating trauma, or bacterial infection)

• Meningismus

• Severe nocturnal or disabling pain

• Unexplained weight loss

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).

Other findings are also helpful. Worsening of pain with flexion is consistent with intervertebral disc 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. Generalized tenderness and nonlocalized allodynia suggests a central pain disorder.

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).

Radiographs can identify most disc 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 discs) 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) and/or C-reactive protein (CRP), 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 ultrasound

• Possibleaortic dissection: Angiography, CT, or MRI

• Symptoms that are disabling or persistent > 6 weeks: Imaging (usually MRI or CT) and, if infection is suspected, WBC count, ESR, and/or CRP; some clinicians begin with anteroposterior and lateral radiographs of the spine to help localize and sometimes diagnose abnormalities

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

It is important to note imaging findings do not always correlate with patient symptoms. Evidence supports that many patients with disc herniations are asymptomatic (1, 2).

1. 1. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am.1990;72(3):403-408.

2. 2. Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69-73. doi:10.1056/NEJM199407143310201

Although a brief initial period (eg, up to 48 hours) 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 night-time use of a cervical collar and contour pillow for sleep. As the pain subsides, patients can participate in a stabilization program.

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.

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 minutes, 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.

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.

Clinicians should reassure patients with acute nonspecific musculoskeletal back pain that the prognosis is generally favorable and that activity and exercise are safe even when they cause some discomfort. Appropriate patient education can also help reduce unnecessary health care utilization (2).

Evidence supporting the efficacy of oral and injected (eg, epidural spinal and facet joint injections [3]) corticosteroids is limited. Some evidence suggests that a course of oral corticosteroids may result in a slight short-term improvement in pain for some patients with radicular low back pain; however, oral corticosteroids are likely to be ineffective for patients with nonradicular low back pain (4). The use of epidural corticosteroid injections for patients with radicular low back pain should be reserved for patients who have not improved with other treatment modalities. If an epidural or facet injection is anticipated, clinicians should obtain an MRI before injection so that the pathology can be identified, localized, and optimally treated.

Radiofrequency denervation is another technique that has been used in patients with nonradicular facet joint-mediated pain, with some evidence supporting improvement in pain and functionality compared with placebo (5). An injection to the dorsal spinal nerve, a medial branch block, or an anesthetic is performed to assess the patient's potential response prior to radiofrequency.

The use of muscle relaxants (eg, cyclobenzaprine, methocarbamol, metaxalone, benzodiazepines) for neck and low back pain is controversial. Benefits of these medications 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 (6). 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 improve quality of sleep and reduce pain.

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 older adults (eg, vertebral artery injury with neck manipulation) and those with severe disc disorders, cervical arthritis, cervical stenosis, or osteoporosis.