Highlights: - History and physical examination, along with risk factors, should dictate additional imaging needs for patients with neck or low back pain. -MRI should be considered in patients with a history of cancer, red flag signs, progressive neurological deficits, determination of fracture acuity, and for pre-surgical or pre-procedure evaluation. - For patients with acute neck pain who receive appropriate treatment, most cases will resolve within a period of weeks to months. - Preferential direction of movement in patients with symptoms of radicular or axial low back pain can guide patient ergonomics and a physical therapy program. - Consulting a spine physiatrist within the first week of the onset of low back symptoms may increase patient satisfaction, decrease utilization of care, and reduce surgery rates |
| Cervical Pain |
> Epidemiology
Neck pain is the fourth leading cause of disability. The adult population (15 to 74 years old) shows a point prevalence that ranges from 5.9% to 38.7%. Women report this condition more frequently than men.
The causes of pain vary widely, the main ones being inadequate ergonomics at work, sitting and maintaining neck posture in a non-physiological position for long periods of time.
> Classification
Non-traumatic cervical pain can be classified according to the suspected pain generator. It may have a mechanical component, a neuropathic component, or a combination of both. The controversial entity of myofascial pain syndrome is a condition that likely encompasses chronic neck pain not explained by imaging findings.
The differential diagnosis for neck pain is broad and should be used in a diagnostic algorithm: coronary artery disease, infection, malignancy (multiple myeloma, metastatic disease), rheumatologic conditions (polymyalgia rheumatica), vascular etiologies (vertebral or carotid dissection) and thoracic outlet syndrome.
Although rare, neck pain conditions that are associated with red flags (e.g., osteomyelitis or suspected malignancy) should be addressed promptly and typically require advanced imaging (MRI or CT) along with specific laboratory testing. (erythrocytes, sedimentation rate, C-reactive protein, complete blood count, etc.).
> History and Physical Examination
Observation of neck and head position and range of motion are an integral part of the physical examination. The doctor should also ask the patient to indicate where the pain is perceived, name the factors that aggravate and relieve it, describe the nature of the pain (dull, lancinating, sharp, electric, radiating or non-radiating), as well as whether the Its extension interferes with sleeping, driving, working, and activities of daily living.
Any antalgic neck position should be noted along with restrictions in active and passive range of motion. Cervical rotation deficits are mainly observed in problems of the upper cervical spine such as atlanto-axial joint pathology. Pathology of the lower cervical spine can manifest with axial pain.
> Significant physical examination maneuvers for patients with neck pain
If tandem walking (walking in a line with one foot in front of the other) is normal, there is a low probability of cord compression or clinically significant spinal stenosis.
If L’Hermitte’s sign (electrical-like sensations in the spine or arms with passive neck flexion) is present, cervical myelopathy should be suspected because this exam finding has a specificity greater than 90%.
A positive Spurling maneuver (lateral flexion and rotation toward the affected side with axial compression of the head reproducing upper limb radicular pain) suggests cervical neuropathic pain/radiculitis with a specificity of 85% to 95% and a sensitivity of 40%. at 60%.
Sustained ankle clonus (>3 beats of clonus with constant pressure on the sole of the forefoot) is significant for an upper motor neuron process such as demyelinating disease or spinal cord compression.
Shoulder abduction, also known as Bakody sign (relief of ipsilateral cervical radicular pain by placing the affected arm overhead by shoulder abduction), indicates cervical radiculitis with a specificity of up to 90% with moderate reliability.
Cervical facet joint pain correlates with poor ergonomics or a flexion/extension injury mechanism. Depending on the level affected, the patient may present with a complaint of occipital or temporoparietal pain (cervicogenic headache) or pain in the upper back and shoulders.
> Diagnosis
In patients with head or neck trauma, the NEXUS criteria and/or the Canadian Cervical Spine Rule should be used to determine the need for imaging. Cervical spine radiographs with flexion and extension views included may determine instability (more than 3 mm difference in alignment between flexion and extension views) in cervical spine segments.
CT scans of the cervical spine are rarely indicated in the absence of trauma and prior surgery to the neck region.
MRI is the most sensitive imaging modality for soft tissue structures (spinal cord, intervertebral disc, synovial cysts) and acute/subacute fractures. MRI should be considered in patients with warning signs, progressive neurological deficits, and for presurgical or preprocedural evaluation.
Given the high rate of radiological abnormalities in asymptomatic individuals, caution should be used when ordering MRIs for chronic neck pain that does not respond to conservative treatment, in patients without warning signs or neurological deficits.
Electrodiagnostic studies are an extension of the physical examination. They should be used if there is no correlation between clinical symptoms and MRI, and to differentiate between cervical radiculopathy, peripheral nerve entrapment in the upper limb (neuropathy) and brachial plexopathy.
Laboratory studies are not essential to evaluate musculoskeletal neck pain unless other causes are suspected (e.g., rheumatologic disorder, infection, malignancy), in which case a complete blood count, erythrocyte sedimentation rate, and protein C reactive may be an option.
> Treatment
In a randomized trial following 206 patients with acute cervical radicular pain, physical therapy, a home exercise program, and use of a hard collar significantly improved pain-related disability at 6 weeks compared with expectant management. .
Although there is no single exercise modality for neck pain, a small prospective randomized trial demonstrated a trend toward greater improvement in the group undergoing the McKenzie Method of physical therapy compared to general exercise.
The evidence that alternative treatments for neck pain, including massage, acupuncture, manipulation, soft cervical collar, electrotherapy, and yoga, are superior to sham or other treatments is weak.
The results of pharmacological interventions for acute and chronic musculoskeletal neck pain are limited. There are no high-quality studies to determine the effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) or oral steroids for neck pain.
Spine surgery is rarely indicated for musculoskeletal axial cervical pain. When neck pain is associated with progressive neurological deficits or spinal cord compression, surgical consultation is indicated. Patients with cervical radiculopathy may benefit in the short term from surgical decompression and/or fusion surgery.
The evidence for the use of biological therapies is non-existent for the treatment of musculoskeletal neck pain. Future research is needed to determine its effectiveness for spinal pain and comparative effectiveness for all types of therapeutics, including spinal surgeries, spinal injection therapies, and drug treatments.
| Low back pain |
> Epidemiology
Low back pain is the leading cause of disability and loss of productivity worldwide, with a prevalence of up to 84% in the adult patient population.
In 2010, low back pain represented 1.3% of diagnoses in an outpatient clinic. Although an acute episode may resolve, up to 70% of patients may experience a recurrent episode within 1 year and 54% of them within 6 months.
Although it is not necessary to determine the benign causes of low back pain, appropriate treatment for predisposing conditions could decrease the chance of patients developing chronic pain, a symptom that could be very difficult to reverse.
In a recent large cohort study of patients seen for acute low back pain in the primary care setting, up to 20% of patients developed chronic low back pain at 2-year follow-up.
A consultation with a physical medicine and rehabilitation specialist within 48 hours for acute pain and within 10 days for all patients with low back pain can significantly reduce the rate of surgical interventions and increase patient satisfaction.
Non-traumatic low back pain can have different etiologies: related to the intervertebral disc, related to the vertebral body, related to the facet joint and related to the sacroiliac joint. In addition, there is low back pain related to infectious, neoplastic (metastatic disease, lymphoma, myeloma, retroperitoneal tumors) and inflammatory arthropathies (ankylosing spondylitis, psoriatic arthritis).
Other causes that can simulate lumbar spine pathology may be related to kidney disease (nephrolithiasis, distention of the renal capsule), pelvic organ pathology, aortic aneurysm or aortic pathology, or gastrointestinal disease (pancreatitis, gastroduodenal ulcer, etc.) .
> Natural History
There is ample evidence that 28% to 65% of patients who have 1 episode of axial back pain do not fully recover 12 months after the initial consultation. Factors associated with ongoing pain included older age, greater initial pain and dysfunction, depression, and fear of persistent pain.
> History and Physical Examination
- History
Low back pain can be classified as acute (<4 weeks), subacute (4 to 12 weeks), or chronic (>12 weeks), regardless of etiology. Low back pain is a relatively rare manifestation of a serious medical illness. Elements of the history should include any previous episodes of current pain, location of pain with the patient pointing to the area of perceived pain, duration of symptoms, preferred relief positions and relief factors, and preferential direction (i.e., movement of lumbar spine or certain position).
Exercise suppresses or centralizes pain radiating to the leg. It is also important to stratify low back pain as radicular (radiation to the lower extremities) versus axial low back pain (no radiation to the lower extremities), determine if the patient has had recent falls, any gait abnormalities, or bowel or bladder incontinence.
- Physical exam
Focused physical examination can determine pathology that would require possible additional specialized care:
• Toe walk and heel walk.
• Use of assistive device.
• Single-leg toe raises (10 each).
• Single leg is raised from the sitting position.
• Weakness in manual muscle testing.
• Pathological reflexes, upper motor neuron signs, neurological deficits (ankle clonus, Hoffman syndrome, difficulty with tandem walking).
• Preferential direction of movement.
• Segmental pain with percussion of the spinous process (compression fracture, metastatic disease in the spine)
> Musculoskeletal Causes of Low Back Pain
Discogenic pain may be the cause of low back pain in patients with vascular ingrowth of the disc, disc uncovering due to spondylolisthesis, or exposure of the disc’s nerve endings to inflammatory mediators. Disc-related pain often worsens with activities such as lifting, bending forward, and a history of sitting intolerance with pain improvement with lying down or standing.
The natural history of lumbar radiculopathy is favorable in the majority of patients. Myotomal weakness should trigger a consultation with a spine specialist who can further evaluate the deficit using electrodiagnostic studies (nerve conduction studies). The extreme case of a lumbar disc herniation can cause severe central stenosis with compression of the cauda equina, resulting in bilateral leg pain, weakness, bladder dysfunction, and changes in perineal sensation. Symptoms of cauda equina require urgent surgical evaluation of the spine.
Pain in the lumbar facet joint can be the cause of back pain, especially in the context of degenerative disc disease or in the setting of severe degeneration of the facet joint cartilage, presence of inflammatory cells and mediators, increased vascularization and subchondral remodeling. This may contribute to the pathology of spinal stenosis.
Another cause of musculoskeletal low back pain may be pain in the sacroiliac joint that occurs as a result of sacroiliitis, falls, or motor vehicle collisions.
When to Refer to a Spine Rehabilitation Specialist or Spine Surgeon: • New back pain for patients 65 years or older. • Back pain that does not improve in 4 to 5 weeks. • Pain that spreads to the lower leg, particularly if accompanied by leg weakness. • Back pain as a result of a fall or accident, especially if patients are over 50 years old. • Pain that does not go away, even at night or when lying down. |
When to refer to a spine surgeon or consider referral to the emergency room: • Urgent evaluation for symptoms that reveal weakness in one or both legs or problems with the bladder, bowel, or sexual dysfunction, which may be signs of cauda equina syndrome, which arises from compression of the nerve bundle at the base of the spine. . • Back pain accompanied by unexplained fever or weight loss. • History of low back pain associated with a history of cancer, a weakened immune system, osteoporosis, or long-term use of corticosteroids. |
> Tests
Laboratory tests may or may not raise the suspicion of a systemic cause of low back pain, such as an inflammatory state, the etiology of an infection, or a tumor. A basic check may include an erythrocyte sedimentation rate, C-reactive protein, and complete blood count.
X-rays can be helpful in identifying cortical bone defects, including fractures, structural defects, or spinal instability. In cases of instability or significant spondylolisthesis, it is reasonable to refer to a spine specialist.
MRI and CT scan of the lumbar spine are useful in identifying more significant abnormalities such as tumors, spondylodiscitis, osteomyelitis or in planning procedures or surgery. These imaging modalities may be indicated for unresolved low back pain within 4 to 5 weeks. MRI is the best imaging modality to evaluate soft tissue changes (herniated disc, spinal cysts, discitis).
Fluoroscopy-guided contrast-enhanced diagnostic blocks performed according to the Spine Intervention Society guidelines are specific and sensitive procedures to identify or rule out a musculoskeletal structure of the spine as a pain generator.
> Treatment
For musculoskeletal nonspecific acute low back pain, there is sufficient evidence for treatment with NSAIDs for up to 3 months. Despite the wide use of these drugs, their significant side effect profile, including cardiovascular events, new-onset atrial fibrillation, congestive heart failure, stroke, heart attack, and drug interactions, must be considered.
There is good evidence for the use of muscle relaxants, especially non-habit-forming ones (cyclobenzaprine) for the treatment of acute low back pain. There is no proven superiority of opioids over NSAIDs and muscle relaxants for the treatment of musculoskeletal axial low back pain.
When performed by highly trained physicians, radiofrequency denervation of the lumbar facet joints can relieve pain in up to 58% of patients who were carefully diagnosed with comparative diagnostic blocks.
There is good evidence that directional preference used in physical therapy sessions can significantly improve lower back and lower extremity symptoms.
For patients with radicular leg pain secondary to a lumbar disc herniation, transforaminal epidural steroid injections have been shown to be effective.
The wide range of widely used physical modalities, behavioral treatments, and physical modalities including massage, acupuncture, therapeutic ultrasound treatments, yoga, Pilates, manipulative spinal therapies are not supported by the same level of evidence as the aforementioned treatments. Any improvement may be due to the natural recovery timeline.
Patient education is probably the most important aspect of the initial visit for acute low back pain with or without radicular symptoms. There is ample evidence that seeing a nonsurgical spinal physiatry specialist within 1 week can increase patient satisfaction, decrease utilization of care, and reduce rates of spinal fusion surgeries for patients with low back pain.
