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).
Table 276-1 Summary
of Risk Factors in Neck and Back Pain |Favorite Table|Download (.pdf)
Table 276-1 Summary
of Risk Factors in Neck and Back Pain
|Historical Risk Factors||Concern/Comments|
|Pain >6 wk||Tumor, infection|
|Age <18 y old, >50 y old||Congenital anomaly, tumor|
|Minor trauma in elderly or rheumatologic disease||Fracture, age >50 y old is a risk for compression fracture,
>70 y old is more specific for fracture|
|History of cancer||Tumor|
|Fever and rigors||Infection|
|Weight loss||Tumor, infection|
|Injection drug use||Infection|
|Night pain||Tumor, infection|
|Unremitting pain, even when supine||Tumor, infection|
|Saddle anesthesia||Epidural compression|
|Severe/progressive neurologic deficit||Epidural compression|
|Anticoagulants and coagulopathy||Epidural compression|
|Physical Risk Factors||Concern|
|Patient writhing in pain||Infection|
|Unexpected anal sphincter laxity||Epidural compression|
|Perianal/perineal sensory loss||Epidural compression|
|Palpable bladder postvoiding||Epidural compression|
|Major motor weakness/gait disturbance||Nerve root or epidural compression|
|Positive straight leg raise test||Herniated disk|
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).
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