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INTRODUCTION

The importance of back and neck pain in our society is underscored by the following: (1) the cost of chronic back pain in the United States is estimated at $177 billion annually; approximately one-third of this cost is due to 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 individuals <45 years of age; (3) low back pain (LBP) is the second most common reason for visiting a physician in the United States; and (4) more than four out of five people will experience significant back pain at some point in their lives.

ANATOMY OF THE SPINE

The anterior spine consists of cylindrical vertebral bodies separated by intervertebral disks and held together by the anterior and posterior longitudinal ligaments. The intervertebral disks are composed of a central gelatinous nucleus pulposus surrounded by a tough cartilaginous ring, the annulus fibrosis. Disks are responsible for 25% of spinal column length and allow the bony vertebrae to move easily upon each other (Figs. 14-1 and 14-2). Desiccation of the nucleus pulposus and degeneration of the annulus fibrosus increase with age, resulting in loss of disk height. The disks are largest in the cervical and lumbar regions where movements of the spine are greatest. The anterior spine absorbs the shock of bodily movements such as walking and running and, with the posterior spine, protects the spinal cord and nerve roots in the spinal canal.

FIGURE 14-1

Vertebral anatomy. (From A Gauthier Cornuelle, DH Gronefeld: Radiographic Anatomy Positioning. New York, McGraw-Hill, 1998; with permission.)

FIGURE 14-2

Spinal column. (From A Gauthier Cornuelle, DH Gronefeld: Radiographic Anatomy Positioning. New York, McGraw-Hill, 1998; with permission.)

The posterior spine consists of the vertebral arches and processes. Each arch consists of paired cylindrical pedicles anteriorly and paired lamina 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 posterior spine provides an anchor for the attachment of muscles and ligaments. The contraction of muscles attached to the spinous and transverse processes and lamina 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 and arm, or low back and buttock or leg, pain (see dermatomes in Figs. 22-2 and 22-3). 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 ...

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