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Cardinal Manifestations Back and Neck Pain
Cardinal Manifestations Back and Neck Pain
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
before exiting.
By contrast, because the spinal cord ends at the vertebral
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
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
tissue anatomy.
Bony lesions of the lateral recess or intervertebral foramen are
with contrast.
Furthermore, in patients with known disk herniation treated either
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
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
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