Back and Neck Pain

LOW BACK PAIN

FIVE TYPES OF LOW BACK PAIN (LBP)

• Local pain—caused by activation of pain-sensitive nerve endings near affected

part of the spine (i.e.,tears,stretching).

• Pain referred to the back—abdominal or pelvic origin; back pain unaffected

by spine movement.

• Pain of spine origin—restricted to the back or referred to lower limbs. Diseases

of upper lumbar spine refer pain to upper lumbar region,groin,or anterior

thighs. Diseases of lower lumbar spine refer pain to buttocks or posterior thighs.

• Radicular pain—radiates from spine to leg in specific nerve root territory.

Coughing, sneezing,lifting heavy objects,or straining may elicit pain.

• Pain associated with muscle spasm—diverse causes; accompanied by taut

paraspinal muscles.

EXAMINATION Include abdomen,pelvis, and rectum to search for visceral

sources of pain. Inspection may reveal scoliosis or muscle spasm. Palpation

may elicit pain over a diseased spine segment. Pain from hip may be confused

with spine pain; manual internal/external rotation of leg at hip (knee and

hip in flexion) reproduces the hip pain. Straight-leg raising (SLR) sign—elicited

by passive flexion of extended leg at the hip with pt in supine position; maneuver

stretches L5/S1 nerve roots and sciatic nerve passing posterior to the hip; SLR

is positive if maneuver reproduces the pain. Crossed SLR sign—positive when

SLR on one leg reproduces symptoms in opposite leg or buttocks; nerve/nerve

root lesion is on the painful side. Reverse SLR sign—passive extension of leg backwards with pt standing; maneuver stretches L2–L4 nerve roots and femoral

nerve passing anterior to the hip. Neurologic exam—search for focal atrophy,

weakness,reflex loss, diminished sensation in a dermatomal distribution. Findings

with radiculopathy are summarized in Table 35-1.

LABORATORY STUDIES “Routine” laboratory studies and lumbar

spine x-rays—rarely needed for acute LBP but indicated when risk factors for

serious underlying disease are present (Table 35-2). MRI and CT-myelography

are tests of choice for anatomic definition of spine disease. Electromyography

(EMG) and nerve conduction studies useful for functional assessment of peripheral

nervous system.

ETIOLOGY Lumbar Disk Disease Common cause of low back and leg

pain; usually at L4-L5 or L5-S1 levels. Dermatomal sensory loss,reduction or

loss of deep tendon reflexes,or myotomal pattern of weakness more informative

than pain pattern for localization. Usually unilateral; bilateral with large central

disk herniations compressing multiple nerve roots—may cause cauda equina

syndrome. Indications for lumbar disk surgery: (1) progressive motor weakness

from nerve root injury,(2) progressive motor impairment by EMG, (3) abnormal

bowel or bladder function,(4) incapacitating nerve root pain despite conservative

treatment for at least 4 weeks,and (5) recurrent incapacitating pain despite

conservative treatment. The latter two criteria are controversial.

Spinal Stenosis A narrowed spinal canal producing neurogenic claudication,

i.e.,back, buttock,and/or leg pain induced by walking or standing and

relieved by sitting. Symptoms are usually bilateral. Unlike vascular claudication,

symptoms are provoked by standing without walking. Unlike lumbar disk disease,

symptoms are relieved by sitting. Focal neurologic deficits common; severe

neurologic deficits (paralysis,incontinence) rare. Stenosis results from acquired

(75%),congenital, or mixed acquired/congenital factors. Symptomatic

treatment adequate for mild disease; surgery indicated when pain interferes with

activities of daily living or focal neurologic signs present. Surgery successful

in 65–80%; 25% develop recurrent stenosis within 5 years.

Trauma Low back strain or sprain used to describe minor,self-limited

injuries associated with LBP. Vertebral fractures from trauma result in wedging

or compression of vertebral bodies; burst fractures involving anterior and posterior

spine elements can occur. Neurologic impairment common with vertebral

fractures; early surgical intervention indicated. Most common cause of nontraumatic fracture is osteoporosis; others are osteomalacia,hyperparathyroidism, hyperthyroidism, multiple myeloma,or metastatic carcinoma; glucocorticoid use may predispose vertebral body to fracture. Clinical context,exam findings,and spine x-rays establish diagnosis.

Spondylolisthesis Slippage of anterior spine forward,leaving posterior elements

behind; L4-L5 _L5-S1 levels; can produce LBP or radiculopathy/cauda

equina syndrome (see Chap. 196).

Osteoarthritis Back pain induced by spine movement. Increases with age;

radiologic findings do not correlate with severity of pain. Facet syndrome—

radicular symptoms and signs,nerve root compression by unilateral facet hypertrophy.

Foraminotomy and facetectomy—long-term pain relief in 80–90%.

Loss of intervertebral disk height reduces vertical dimensions of intervertebral

foramen; descending pedicle can compress the exiting nerve root.

Vertebral Metastases Back pain most common neurologic symptom in

patients with systemic cancer. Metastatic carcinoma,multiple myeloma, and

lymphomas frequently involve spine. Back pain may be presenting symptom of cancer; pain typically unrelieved by rest. MRI or CT-myelography demonstrates

vertebral body metastasis; disk space is spared.

Vertebral Osteomyelitis Back pain unrelieved by rest; focal spine tenderness,

elevated ESR. Primary source of infection (lung,urinary tract, or skin)

found in 40%; IV drug abuse a risk factor. Destruction of the vertebral bodies

and disk space common. Lumbar spinal epidural abscess presents as back pain

and fever; exam may be normal or show radicular findings,spinal cord involvement, or cauda equina syndrome; abscess extent best defined by MRI.

Lumbar Arachnoiditis May follow inflammatory response to local tissue

injury within subarachnoid space; fibrosis results in clumping of nerve roots,

best seen by MRI; treatment is unsatisfactory.

Immune Disorders Ankylosing spondylitis,rheumatoid arthritis, Reiter’s

syndrome,psoriatic arthritis,and chronic inflammatory bowel disease. Ankylosing

spondylitis—typically male _40 years with nocturnal back pain; pain

unrelieved by rest but improves with exercise.

Osteoporosis Loss of bone substance resulting from hyperparathyroidism,

chronic glucocorticoid use,immobilization, or other medical disorders. Sole

manifestation may be back pain exacerbated by movement.

Visceral Diseases (Table 35-3) Pelvis refers pain to sacral region,lower

abdomen to lumbar region,upper abdomen to lower thoracic or upper lumbar

region. Local signs are absent; normal movements of the spine are painless. A

contained rupture of abdominal aortic aneurysm may produce isolated back

pain.

Other Chronic LBP with no clear cause; psychiatric disorders,substance

abuse may be associated.

TREATMENT

Acute Low Back Pain (ALBP)

Pain of _3 months’ duration; full recovery occurs in 85%. Management controversial; few well-controlled clinical trials exist.

Visceral Causes of Low Back Pain

Stomach (posterior wall)—Gallbladder—gallstones

Pancreas—tumor,cyst, pancreatitis

Retroperitoneal—hemorrhage,tumor, pyelonephritis

Vascular—abdominal aortic aneurysm,renal artery and vein thrombosis

Colon—colitis,diverticulitis, neoplasm

Uterosacral ligaments—endometriosis,carcinoma

Uterine malposition

Menstrual pain

Neoplastic infiltration of nerves

Radiation neurosis of tumors/nerves

Prostate—carcinoma,prostatitis

Kidney—renal stones,inflammatory disease, neoplasm, infection

Fig. 35-1. If “risk factors” (Table 35-2) are absent,initial treatment is symptomatic

and no diagnostic tests necessary. Spine infections,fractures, tumors,

or rapidly progressive neurologic deficits require urgent diagnostic evaluation.

Patients with no risk factors and no improvement over 4 weeks are subdivided

by the presence/absence of leg symptoms and managed accordingly.

Clinical trials do not show benefit from bed rest_2 days. Possible benefits

of early activity—cardiovascular conditioning,disk and cartilage nutrition,

bone and muscle strength,increased endorphin levels. Studies of traction or

posture modification fail to show benefit. Proof lacking to support acupuncture,

ultrasound,diathermy,transcutaneous electrical nerve stimulation, massage,

biofeedback, or electrical stimulation. Self-application of ice or heat or

use of shoe insoles is optional given low cost and risk; benefit of exercises

uncertain. A short course of spinal manipulation or physical therapy may

lessen pain and improve function. Temporary suspension of activities known

to increase mechanical stress on the spine (heavy lifting,straining at stool,

prolonged sitting/bending/twisting) may relieve symptoms. Value of education

(“back school”) in long-term prevention is unclear.

Pharmacologic treatment of ALBP includes NSAIDs and acetaminophen.

Muscle relaxants (cyclobenzaprine,methocarbanol) provide short-term benefit

(4–7 days),but drowsiness limits use. Opioids are not superior to NSAIDs

or acetaminophen for ALBP. Epidural anesthetics,glucocorticoids, opioids,

or tricyclic antidepressants are not indicated as initial treatment.

Chronic Low Back Pain (CLBP)

Pain lasting _3 months; differential diagnosis includes most conditions described

above. CLBP causes can be clarified by neuroimaging and EMG/nerve

conduction studies; diagnosis of radiculopathy secure when results concordant

with findings on neurologic exam. Management is complex and not amenable

to a simple algorithmic approach. Treatment based upon identification of underlying cause; when specific cause not found,conservative management necessary.

Pharmacologic and comfort measures similar to those described for

ALBP. Exercise (“work hardening”) regimens effective in returning some pts

to work,diminishing pain, and improving walking distances. Hydrotherapy

may be useful,and some pts experience short-term pain relief with percutaneous

electrical nerve stimulation.Surgical intervention based upon neuroimaging

alone not recommended: up to one-third of asymptomatic young adults

have a herniated lumbar disk by CT or MRI.

NECK AND SHOULDER PAIN

ETIOLOGY Trauma to the Cervical Spine Whiplash injury is due to

trauma (usually automobile accidents) causing cervical musculoligamental

sprain or strain due to hyperflexion or hyperextension. This diagnosis should

not be applied to pts with fractures,disk herniation, head injury, or altered

consciousness. In one study,18% of pts with whiplash injury had persistent

injury-related symptoms 2 years after the car accident.

Cervical Disk Disease Herniation of a lower cervical disk is a common

cause of neck,shoulder,arm, or hand pain. Neck pain (worse with movement),

stiffness,and limited range of neck motion are common. With nerve root compression, pain may radiate into a shoulder or arm. Extension and lateral rotation of the neck narrows the intervertebral foramen and may reproduce radicular symptoms (Spurling’s sign). In young individuals,acute radiculopathy from a ruptured disk is often traumatic. Subacute radiculopathy is less likely to be

related to a specific traumatic incident and may involve both disk disease and

spondylosis. Clinical features of cervical nerve root lesions are summarized in

Table 35-4.

Cervical Spondylosis Osteoarthritis of the cervical spine may produce

neck pain that radiates into the back of the head,shoulders, or arms; can also

be source of headaches in the posterior occipital region. A combined radiculopathy

and myelopathy may occur. An electrical sensation elicited by neck

flexion and radiating down the spine from the neck (Lhermitte’s symptom)

usually indicates cervical or upper thoracic spinal cord involvement. MRI or

CT-myelography can define the anatomic abnormalities,and EMG and nerve

conduction studies can quantify the severity and localize the levels of nerve

root injury.

Other Causes of Neck Pain Includes rheumatoid arthritis of the cervical

apophyseal joints,ankylosing spondylitis, herpes zoster (shingles), neoplasms

metastatic to the cervical spine, infections (osteomyelitis and epidural abscess),

and metabolic bone diseases. Neck pain may also be referred from the heart

with coronary artery ischemia (cervical angina syndrome).

Thoracic Outlet An anatomic region containing the first rib,the subclavian

artery and vein,the brachial plexus,the clavicle, and the lung apex. Injury may

result in posture- or task-related pain around the shoulder and supraclavicular

region. True neurogenic thoracic outlet syndrome results from compression of

the lower trunk of the brachial plexus by an anomalous band of tissue; treatment

consists of surgical division of the band. Arterial thoracic outlet syndrome results

from compression of the subclavian artery by a cervical rib; treatment is

with thrombolyis or anticoagulation,and surgical excision of the cervical rib.

Disputed thoracic outlet syndrome includes a large number of patients with

chronic arm and shoulder pain of unclear cause; surgery is controversial,and

treatment often unsuccessful.

Brachial Plexus and Nerves Pain from injury to the brachial plexus or

arm peripheral nerves can mimic pain of cervical spine origin. Neoplastic infiltration can produce this syndrome,as can postradiation fibrosis (pain less often

present). Acute brachial neuritis consists of acute onset of severe shoulder or

scapular pain followed over days by weakness of proximal arm and shoulder

girdle muscles innervated by the upper brachial plexus; onset often preceded

by an infection or immunization. Complete recovery occurs in 75% of pts after

2 years and in 89% after 3 years.

Shoulder If signs of radiculopathy are absent,differential diagnosis includes

mechanical shoulder pain (tendonitis,bursitis,rotator cuff tear, dislocation,

adhesive capsulitis,and cuff impingement under the acromion) and referred

pain (subdiaphragmatic irritation,angina,Pancoast tumor). Mechanical

pain is often worse at night,associated with shoulder tenderness, and aggravated

by abduction,internal rotation, or extension of the arm.

TREATMENT

Symptomatic treatment of neck pain includes analgesic medications and/or a

soft cervical collar. Indications for cervical disk and lumbar disk surgery are

similar; however,with cervical disease an aggressive approach is indicated if

spinal cord injury is threatened. Surgery of cervical herniated disks consists

of an anterior approach with diskectomy followed by anterior interbody fusion;

a simple posterior partial laminectomy with diskectomy is an acceptable

alternative. The cumulative risk of subsequent radiculopathy or myelopathy

at cervical segments adjacent to the fusion is 3% per year and 26% per decade.

Nonprogressive cervical radiculopathy (associated with a focal neurologic

deficit) due to a herniated cervical disk may be treated conservatively with a

high rate of success. Cervical spondylosis with bony,compressive cervical

radiculopathy is generally treated with surgical decompression to interrupt the

progression of neurologic signs; spondylotic myelopathy is managed with anterior

decompression and fusion or laminectomy.