Cardinal Manifestations and

Presentation of Diseases
dr Budi Enoch SpPD
Back and Neck Pain
dr Budi Enoch SpPD
 The importance of back and neck pain in our society is
underscored by the following:
 (1) the cost of back pain in the United States exceeds
$100 billion annually; approximately one-third of these
costs are direct health care expenses, and two-thirds are
indirect costs resulting from loss of wages and
productivity;
 (2) back symptoms are the most common cause of
disability in those <45 years;
 (3) low back pain is the second most common reason for
visiting a physician in the United States; and (4) ~1% of
the U.S. population is chronically disabled because of
back pain.
Anatomy of the Spine

Vertebral anatomy. (From A Gauthier Cornuelle, DH Gronefeld:

Radiographic Anatomy Positioning. New York, McGraw-Hill, 1998
 The posterior portion of the spine consists of the
vertebral arches and processes.
 Each arch consists of paired cylindrical pedicles
anteriorly and paired laminae posteriorly.
 The vertebral arch also gives rise to two transverse
processes laterally, one spinous process posteriorly,
plus two superior and two inferior articular facets.
 The apposition of a superior and inferior facet
constitutes a facet joint.
 The functions of the posterior spine are to protect the
spinal cord and nerves within the spinal canal and to
provide an anchor for the attachment of muscles and
ligaments.
 The contraction of muscles attached to the spinous and
transverse processes and laminae works like a system
of pulleys and levers that results in flexion, extension,
and lateral bending movements of the spine.
 Nerve root injury (radiculopathy) is a common cause of
neck, arm, low back, buttock, and leg pain .
 The nerve roots exit at a level above their respective

vertebral bodies in the cervical region (e.g., the C7 nerve

root exits at the C6-C7 level) and below their respective
vertebral bodies in the thoracic and lumbar regions (e.g.,
the T1 nerve root exits at the T1-T2 level).
 The cervical nerve roots follow a short intraspinal course

before exiting.
 By contrast, because the spinal cord ends at the vertebral

L1 or L2 level, the lumbar nerve roots follow a long

intraspinal course and can be injured anywhere from the
upper lumbar spine to their exit at the intervertebral
foramen.
 For example, disk herniation at the L4-L5 level can

produce not only L5 root compression, but also

compression of the traversing S1 nerve root.
Approach to the Patient
 Understanding the types of pain reported by
patients is the essential first step.
 Attention is also focused on identification of

risk factors for serious underlying diseases;

the majority of these are due to
radiculopathy, fracture, tumor, infection, or
referred pain from visceral structures
 Local pain is caused by injury to pain-sensitive structures that compress or
irritate sensory nerve endings. The site of the pain is near the affected part of the
back.
 Pain referred to the back may arise from abdominal or pelvic viscera. The pain is

usually described as primarily abdominal or pelvic but is accompanied by back

pain and usually unaffected by posture. The patient may occasionally complain of
back pain only.
 Pain of spine origin may be located in the back or referred to the buttocks or

legs. Diseases affecting the upper lumbar spine tend to refer pain to the lumbar
region, groin, or anterior thighs. Diseases affecting the lower lumbar spine tend
to produce pain referred to the buttocks, posterior thighs, or rarely the calves or
feet. Referred or "sclerotomal" pain may explain instances where the pain crosses
multiple dermatomes without evidence of nerve root compression.
 Radicular back pain is typically sharp and radiates from the low back to a leg

within the territory of a nerve root. Coughing, sneezing, or voluntary contraction

of abdominal muscles (lifting heavy objects or straining at stool) may elicit the
radiating pain. The pain may increase in postures that stretch the nerves and
nerve roots. Sitting with the leg outstretched places traction on the sciatic nerve
and L5 and S1 roots because the nerve passes posterior to the hip. The femoral
nerve (L2, L3, and L4 roots) passes anterior to the hip and is not stretched by
sitting. The description of the pain alone often fails to distinguish between
sclerotomal pain and radiculopathy.
 Pain associated with muscle spasm, although of obscure origin, is commonly

associated with many spine disorders. The spasms are accompanied by abnormal
posture, tense paraspinal muscles, and dull or achy pain in the paraspinal region.
Examination of the Back
 A physical examination that includes the abdomen and rectum is
advisable. Back pain referred from visceral organs may be reproduced
during palpation of the abdomen [pancreatitis, abdominal aortic aneurysm
(AAA)] or percussion over the costovertebral angles (pyelonephritis).
 The normal spine has a cervical and lumbar lordosis, and a thoracic
kyphosis. Exaggeration of these normal alignments may result in
hyperkyphosis of the thoracic spine or hyperlordosis of the lumbar spine.
 Inspection may reveal a lateral curvature of the spine (scoliosis) or an
asymmetry in the prominence of the paraspinal muscles, suggesting
muscle spasm. Back pain of bony spine origin is often reproduced by
palpation or percussion over the spinous process of the affected vertebrae.
 Forward bending is often limited by paraspinal muscle spasm; the latter
may flatten the usual lumbar lordosis. Flexion at the hips is normal in
patients with lumbar spine disease, but flexion of the lumbar spine is
limited and sometimes painful. Lateral bending to the side opposite the
injured spinal element may stretch the damaged tissues, worsen pain, and
limit motion. Hyperextension of the spine (with the patient prone or
standing) is limited when nerve root compression, facet joint pathology, or
other bony spine disease is present
 CT scanning is superior to routine x-rays for the detection
of fractures involving posterior spine structures,
craniocervical and craniothoracic junctions, C1 and C2
vertebrae, bone fragments within the spinal canal, or
misalignment;
 CT scans are increasingly used as a primary screening

modality for moderate to severe trauma. In the absence of

risk factors, these imaging studies are rarely helpful in
nonspecific ALBP.
 MRI and CT-myelography are the radiologic tests of choice

for evaluation of most serious diseases involving the spine.

 MRI is superior for the definition of soft tissue structures,

whereas CT-myelography provides optimal imaging of the

lateral recess of the spinal canal, and is better tolerated by
claustrophobic patients.
 While the added diagnostic value of modern neuroimaging

is significant, there is concern that these studies may be

overutilized in patients with benign ALBP.
Lumbar Disk Disease
 This is a common cause of chronic or recurrent low back and leg
pain.
 Disk disease is most likely to occur at the L4-L5 or L5-S1 levels,
but upper lumbar levels are involved occasionally.
 The cause is often unknown; the risk is increased in overweight
individuals.
 Disk herniation is unusual prior to age 20 years and is rare in the
fibrotic disks of the elderly.
 Genetic factors may play a role in predisposing some patients to
disk disease.
 The pain may be located in the low back only or referred to a leg,
buttock, or hip. A sneeze, cough, or trivial movement may cause
the nucleus pulposus to prolapse, pushing the frayed and
weakened annulus posteriorly.
 With severe disk disease, the nucleus may protrude through the
annulus (herniation) or become extruded to lie as a free fragment
in the spinal canal.
 The mechanism by which intervertebral disk injury
causes back pain is controversial.
 The inner annulus fibrosus and nucleus pulposus
are normally devoid of innervation.
 Inflammation and production of proinflammatory
cytokines within the protruding or ruptured disk
may trigger or perpetuate back pain.
 Ingrowth of nociceptive (pain) nerve fibers into
inner portions of a diseased disk may be
responsible for chronic "diskogenic" pain.
 Nerve root injury (radiculopathy) from disk
herniation may be due to compression,
inflammation, or both; pathologically,
demyelination and axonal loss are usually present.
 A lumbar spine MRI scan or CT-myelogram is necessary to establish
the location and type of pathology.
 Spine MRIs yield exquisite views of intraspinal and adjacent soft

tissue anatomy.
 Bony lesions of the lateral recess or intervertebral foramen are

optimally visualized by CT-myelography. The correlation of

neuroradiologic findings to symptoms, particularly pain, is not
simple.
 Contrast-enhancing tears in the annulus fibrosus or disk

protrusions are widely accepted as common sources of back pain;

however, studies have found that many asymptomatic adults have
similar findings.
 Asymptomatic disk protrusions are also common and may enhance

with contrast.
 Furthermore, in patients with known disk herniation treated either

medically or surgically, persistence of the herniation 10 years later

had no relationship to the clinical outcome.
 In summary, MRI findings of disk protrusion, tears in the annulus

fibrosus, or contrast enhancement are common incidental findings

that, by themselves, should not dictate management decisions for
patients with back pain.
Cauda equina syndrome (CES)
 signifies an injury of multiple lumbosacral nerve roots within the
spinal canal distal to the termination of the spinal cord at L1-2.
 Low back pain, weakness and areflexia in the legs, saddle
anesthesia, or loss of bladder function may occur.
 The problem must be distinguished from disorders of the lower
spinal cord (conus medullaris syndrome), acute transverse
myelitis, and Guillain-Barré syndrome.
 Combined involvement of the conus medullaris and cauda
equina can occur.
 CES is commonly due to a ruptured lumbosacral intervertebral
disk, lumbosacral spine fracture, hematoma within the spinal
canal (e.g., following lumbar puncture in patients with
coagulopathy), compressive tumor, or other mass lesion.
 Treatment options include surgical decompression, sometimes
urgently, in an attempt to restore or preserve motor or sphincter
function, or radiotherapy for metastatic tumors
Treatment Back Pain
 Acute Low Back Pain (ALBP) Without
Radiculopathy
 ALBP is defined as pain of <3 months' duration.
 Full recovery can be expected in 85% of adults with
ALBP without leg pain.
 Most have purely "mechanical" symptoms (i.e., pain
that is aggravated by motion and relieved by rest).
 The initial assessment excludes serious causes of spine
pathology that require urgent intervention, including
infection, cancer, or trauma.
 Risk factors for a serious cause of ALBP are shown in
Table 15-1. Laboratory and imaging studies are
unnecessary if risk factors are absent.
 CT or plain spine films are rarely indicated in the first
month of symptoms unless a spine fracture is
suspected.
 In general, the best activity recommendation is for walking and early
resumption of normal physical activity, avoiding only strenuous manual
labor.
 Possible advantages of early ambulation for acute back pain include
maintenance of cardiovascular conditioning, improved disk and cartilage
nutrition, improved bone and muscle strength, and increased endorphin
levels.
 Application of heat by heating pads or heated blankets is sometimes
helpful.
 acetaminophen and NSAIDs are first-line options for the treatment of
ALBP. Skeletal muscle relaxants, such as cyclobenzaprine or
methocarbamol, may be useful, but sedation is a common side effect.
 Limiting the use of muscle relaxants to nighttime only may be an option
for some patients.
 Because of the risk of abuse of some drugs in this category, including
benzodiazepines and carisoprodol, short courses are generally
recommended
 There is no evidence to support use of oral or injected glucocorticoids for
acute low back pain without radiculopathy.
 Antiepileptic drugs, such as gabapentin, are not FDA approved for treating
low back pain, and there is insufficient evidence to support their use in
this setting
 Chronic Low Back Pain Without
Radiculopathy
 Chronic low back pain is defined as pain lasting >12
weeks; it accounts for 50% of total back pain costs.
 Risk factors include obesity, female gender, older age,

prior history of back pain, restricted spinal mobility, pain

radiating into a leg, high levels of psychological distress,
poor self-rated health, minimal physical activity,
smoking, job dissatisfaction, and widespread pain.
 In general, the same treatments that are recommended

for acute low back pain can be useful for patients with
chronic low back pain.
 In this setting, however, the benefit of opioid therapy or

muscle relaxants is less clear.

 Evidence supports the use of exercise therapy, and this can be one
of the mainstays of treatment for chronic back pain.
 Effective regimens have generally included a combination of
gradually increasing aerobic exercise, strengthening exercises, and
stretching exercises.
 Motivating patients is sometimes challenging, and supervised
exercise is best, for example, with a supportive physical therapist.
 In general, activity tolerance is the primary goal, while pain relief is
secondary.
 Medications for chronic low back pain may include acetaminophen,
NSAIDs, and tricyclic antidepressants
 Psychological treatments are aimed at reducing disability by
modifying cognitive processes and environmental contingencies.
 Cognitive-behavioral therapy includes efforts to identify and modify
patients' thinking about their pain and disability by strategies that
may involve imagery, attention diversion, or modifying maladaptive
thoughts, feelings, and beliefs.
 Alternative treatments, the most common of these for back pain are
spinal manipulation, acupuncture, and massage.
 Various injections, including epidural glucocorticoid
injections, facet joint injections, and trigger point injections
have been used for treating chronic low back pain. However,
in the absence of radiculopathy, there is no evidence that
epidural glucocorticoids are effective for treating chronic
back pain
 Another category of intervention for chronic back pain

includes electrothermal and radiofrequency therapies.

 Surgical intervention for chronic low back pain in the

absence of radiculopathy has been evaluated in a small

number of randomized trials, all conducted in Europe. Each
of these studies included patients with back pain and a
degenerative disc, but no sciatica. Three of the four trials
concluded that lumbar fusion surgery was no more effective
than highly structured, rigorous rehabilitation combined
with cognitive-behavioral therapy
 The newest surgical treatment for degenerated discs with

back pain is disc replacement with prosthetic disks

 Low Back Pain with Radiculopathy
 A common cause of back pain with radiculopathy is a herniated disc with nerve root
impingement, resulting in back pain with radiation down the leg. The prognosis for
acute low back pain with radiculopathy due to disk herniation (sciatica) is generally
favorable, with most patients demonstrating substantial improvement over a matter of
months. Serial imaging studies suggest spontaneous regression of the herniated portion
of the disc in two-thirds of patients over 6 months. Nonetheless, there are several
important treatment options for providing symptom relief while this natural healing
process unfolds.
 Resumption of normal activity as much as possible is usually the best activity
recommendation. Randomized trial evidence suggests that bed rest is ineffective for
treating sciatica as well as for back pain alone.
 Acetaminophen and NSAIDs are appropriate for pain relief, although severe pain may
require short courses of opioid analgesics
 Epidural glucocorticoid injections have a role in providing temporary symptom relief for
sciatica due to a herniated disc
 Surgical intervention is indicated for patients who have progressive motor weakness,
demonstrated on clinical examination or EMG, as a result of nerve root injury. Urgent
surgery is recommended for patients who have evidence of the cauda equina syndrome
or spinal cord compression, generally suggested by bowel or bladder dysfunction,
diminished sensation in a saddle distribution, a sensory level, bilateral leg weakness, or
bilateral leg spasticity
Pain in the Neck and Shoulder
 Neck pain, which usually arises from diseases of the cervical spine
and soft tissues of the neck, is common.
 Neck pain arising from the cervical spine is typically precipitated by

movement and may be accompanied by focal tenderness and

limitation of motion.
 Pain arising from the brachial plexus, shoulder, or peripheral nerves

can be confused with cervical spine disease, but the history and
examination usually identify a more distal origin for the pain.
 Cervical spine trauma, disk disease, or spondylosis with

intervertebral foraminal narrowing may be asymptomatic or painful

and can produce a myelopathy, radiculopathy, or both.
 The same risk factors for a serious cause of low back pain are

thought to apply to neck pain with the addition that neurologic signs
of myelopathy (incontinence, sensory level, spastic legs) may also
occur. Lhermitte's sign, an electrical shock down the spine with neck
flexion, suggests cervical spinal cord involvement from any cause.
 Treatment Neck Pain Without
Radiculopathy
 The evidence regarding treatment for neck pain is less complete than that
for low back pain.
 As with low back pain, spontaneous improvement is the norm for acute neck
pain, and the usual goal of therapy is to provide symptom relief while natural
healing processes proceed.
 The evidence in support of nonsurgical treatments for whiplash-associated
disorders is generally of poor quality and neither supports nor refutes the
effectiveness of common treatments used for symptom relief.
 Gentle mobilization of the cervical spine combined with exercise programs
may be more beneficial than usual care.
 Evidence is insufficient to recommend for or against the use of cervical
traction, neck collars, TENS, ultrasound, diathermy, or massage.
 The role of acupuncture for neck pain also remains ambiguous, with poor-
quality studies and conflicting results.
 For patients with neck pain unassociated with trauma, supervised exercise,
with or without mobilization, appears to be effective.
 Exercises often include shoulder rolls and neck stretches.
 Although there is relatively little evidence about the use of muscle relaxants,
analgesics, and NSAIDs in neck pain, many clinicians use these medications
in much the same way as for low back pain.
 Treatment Neck Pain with
Radiculopathy
 The natural history of neck pain even with radiculopathy is favorable,
and many patients will improve without specific therapy.
 Although there are no randomized trials of NSAIDs for neck pain, a

course of NSAIDs, with or without muscle relaxants, may be

appropriate initial therapy.
 Other nonsurgical treatments are commonly used, including opioid

analgesics, oral glucocorticoids, cervical traction, and immobilization

with a hard or soft cervical collar.
 However, there are no randomized trials to establish the

effectiveness of these treatments in comparison to natural history

alone.
 Soft cervical collars can be modestly helpful by limiting spontaneous

and reflex neck movements that exacerbate pain.

 As for lumbar radiculopathy, epidural glucocorticoids may provide

short-term symptom relief in cervical radiculopathy

 Surgical treatments include anterior cervical diskectomy alone,

laminectomy with discectomy, discectomy with fusion, and disk

arthroplasty (implanting an artificial cervical disk).
makasih deh...........