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There are many causes of neck and back pain, including trauma and biomechanical injuries, degeneration, inflammation (arthritides), infection (e.g., diskitis, meningitis, epidural abscess), infiltration (e.g., metastatic cancer and spinal cord tumors), and compression (e.g., epidural hematoma and abscess).1–3 In many cases of atraumatic neck and back pain, no specific cause can be identified. The best approach to this complaint is to perform a systematic evaluation based on risk factors in the history and physical examination and let this guide diagnostic testing and management (Table 276-1).

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Table 276-1 Summary of Risk Factors in Neck and Back Pain

Neck and back pain are common and costly societal problems that are among the symptoms most commonly seen in clinical practice. In fact, low back pain alone accounts for approximately 2% of all physician office visits, with only routine examinations, hypertension, and diabetes resulting in more office visits.1 The prevalence and costs associated with these conditions is impressive. In 2002, the 3-month prevalence of low back and neck pain in U.S. adults was 34 million and 9 million, respectively.2 Nearly one fourth of persons with one of these conditions self-reported physical functioning limitations, and inflation-adjusted health care expenditures of patients with spine problems increased 65% from 1997 to 2005.3 It is estimated that the economic burden for spine problems in 2005 was >$85 billion, with only expenditures for heart disease and stroke being substantially higher.3


The anatomy of the spine varies considerably from the base of the skull to the low back. Knowledge of this variable and complex anatomy helps to differentiate benign versus potentially more dangerous causes of neck and back pain. When assessing for a potential anatomic basis to explain a patients symptoms, reviewing sensory dermatomes and spinal nerve interventions of muscles will greatly aid in the diagnosis (Figure 276-1 and see Chapter e158.1, The Neurologic Examination in the Emergency Setting, and Chapter 255, Spine and Spinal Cord Trauma).

Figure 276-1.

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