122 PART 2 Cardinal Manifestations and Presentation of Diseases

Normal

Thecal sac Normal

Nerve roots

Normal

Thecal sac Normal

Nerve roots

Facet joints

Compressed Thecal sac

A B

FIGURE 17-5 Spinal stenosis. A. An axial T2-weighted image of the normal lumbar spine shows a

normal thecal sac within the lumbar spinal canal. The thecal sac is bright. The lumbar roots are seen as

dark punctate dots located posteriorly in the thecal sac. B. The thecal sac is not well visualized due to

severe lumbar spinal canal stenosis, partially the result of hypertrophic facet joints.

Severe right L5-S1 foraminal stenosis (*)

Stenotic L5-S1

foramen

Normal lateral

recesses Stenotic L5-S1

foramen Normal L4-5 foramen

A B

Normal L5-S1

foramen

FIGURE 17-6 Foraminal stenosis. A. Sagittal T2-weighted image reveals normal high signal around the exiting right L4 nerve root in the right neural foramen at L4-L5;

effacement of the high signal is noted one level below at L5-S1, due to severe foraminal stenosis. B. Axial T2-weighted image at the L5-S1 level demonstrates normal lateral

recesses bilaterally, a normal intervertebral foramen on the left, but a severely stenotic foramen (*) on the right.

daily living or when focal neurologic signs are present. Most patients

with neurogenic claudication who are treated medically do not

improve over time. Surgical management with laminectomy, which

increases the spinal canal diameter and reduces venous hypertension,

can produce significant relief of exertional back and leg pain, leading

to less disability and improved functional outcomes. Laminectomy and

fusion is usually reserved for patients with LSS and spondylolisthesis.

Predictors of a poor surgical outcome include impaired walking preoperatively, depression, cardiovascular disease, and scoliosis. Up to

one-quarter of surgically treated patients develop recurrent stenosis at

the same or an adjacent spinal level within 7–10 years; recurrent symptoms usually respond to a second surgical decompression.

Neural foraminal narrowing or lateral recess stenosis with radiculopathy is a common consequence of osteoarthritic processes that cause

LSS (Figs. 17-1 and 17-6), including osteophytes, lateral disk protrusion, calcified disk-osteophytes, facet joint hypertrophy, uncovertebral

joint hypertrophy (in the cervical spine), congenitally

shortened pedicles, or, frequently, a combination of

these processes. Neoplasms (primary or metastatic),

fractures, infections (epidural abscess), or hematomas

are less frequent causes. Most common is bony foraminal narrowing leading to nerve root ischemia and

persistent symptoms, in contrast to inflammation that

is associated with a paracentral herniated disk and

radiculopathy. These conditions can produce unilateral nerve root symptoms or signs due to compression

at the intervertebral foramen or in the lateral recess;

symptoms are indistinguishable from disk-related

radiculopathy, but treatment may differ depending on

the etiology. The history and neurologic examination

alone cannot distinguish between these possibilities.

Neuroimaging (CT or MRI) is required to identify the

anatomic cause. Neurologic findings from the examination and EMG can help direct the attention of the

radiologist to specific nerve roots, especially on axial

images. For facet joint hypertrophy with foraminal

stenosis, surgical foraminotomy produces long-term

relief of leg and back pain in 80–90% of patients.

Facet joint or medial branch blocks for back or neck

pain are sometimes used to help determine the anatomic origin of back

pain or for treatment, but there is a lack of clinical data to support their

utility. Medical causes of lumbar or cervical radiculopathy unrelated to

primary spine disease include infections (e.g., herpes zoster and Lyme

disease), carcinomatous meningitis, diabetes, and root avulsion or

traction (trauma).

■ SPONDYLOSIS AND SPONDYLOLISTHESIS

Spondylosis, or osteoarthritic spine disease, typically occurs in later

life and primarily involves the cervical and lumbosacral spine.

Patients often complain of back pain that increases with movement, is associated with stiffness, and is better with inactivity. The

relationship between clinical symptoms and radiologic findings is

usually not straightforward. Pain may be prominent when MRI, CT,

or x-ray findings are minimal, and prominent degenerative spine

disease can be seen in asymptomatic patients. Osteophytes, combined

123Back and Neck Pain CHAPTER 17

disk-osteophytes, or a thickened ligamentum flavum may cause or

contribute to central spinal canal stenosis, lateral recess stenosis, or

neural foraminal narrowing.

Spondylolisthesis is the anterior slippage of the vertebral body, pedicles, and superior articular facets, leaving the posterior elements behind.

Spondylolisthesis can be associated with spondylolysis, congenital

anomalies, degenerative spine disease, or other causes of mechanical

weakness of the pars interarticularis (e.g., infection, osteoporosis, tumor,

trauma, earlier surgery). The slippage may be asymptomatic or may

cause LBP, nerve root injury (the L5 root most frequently), symptomatic

spinal stenosis, or CES in rare severe cases. A “step-off” on palpation

or tenderness may be elicited near the segment that has “slipped” (most

often L4 on L5 or occasionally L5 on S1). Focal anterolisthesis or retrolisthesis can occur at any cervical or lumbar level and be the source of neck

or LBP. Plain x-rays of the low back or neck in flexion and extension will

reveal movement at the abnormal spinal segment. Surgery is performed

for spinal instability (slippage 5–8 mm) and considered for pain symptoms that do not respond to conservative measures (e.g., rest, physical

therapy), cases with a progressive neurologic deficit, or scoliosis.

■ NEOPLASMS

Back pain is the most common neurologic symptom in patients with

systemic cancer and is the presenting symptom in 20%. The cause is

usually vertebral body metastasis (85–90%) but can also result from

spread of cancer through the intervertebral foramen (especially with

lymphoma), carcinomatous meningitis, or metastasis to the spinal

cord. The thoracic spine is most often affected. Cancer-related back

pain tends to be constant, dull, unrelieved by rest, and worse at night.

By contrast, mechanical causes of LBP usually improve with rest. MRI,

CT, and CT myelography are the studies of choice when spinal metastasis is suspected. Once a metastasis is found, imaging of the entire

spine is essential, as it reveals additional tumor deposits in one-third of

patients. MRI is preferred for soft tissue definition, but the most rapidly available imaging modality is best because the patient’s condition

may worsen quickly without intervention. Early diagnosis is crucial. A

strong predictor of outcome is baseline neurologic function prior to

diagnosis. Half to three-quarters of patients are nonambulatory at the

time of diagnosis and few regain the ability to walk. The management

of spinal metastasis is discussed in detail in Chap. 90.

■ INFECTIONS/INFLAMMATION

Vertebral osteomyelitis is most often caused by hematogenous seeding

of staphylococci, but other bacteria or tuberculosis (Pott’s disease) may

be responsible. The primary source of infection is usually the skin or

urinary tract. Other common sources of bacteremia are IV drug use,

poor dentition, endocarditis, lung abscess, IV catheters, or postoperative wound sites. Back pain at rest, tenderness over the involved

vertebra, and an elevated erythrocyte sedimentation rate (ESR) or

C-reactive protein (CRP) are the most common findings in vertebral

osteomyelitis. Fever or an elevated white blood cell count is found in

a minority of patients. MRI and CT are sensitive and specific for early

detection of osteomyelitis. The intervertebral disk can also be affected

by infection (diskitis) and almost never by tumor. Extension of the

infection posteriorly from the vertebral body can produce a spinal

epidural abscess.

Spinal epidural abscess (Chap. 442) presents with back pain (aggravated by movement or palpation of the spinous process), fever, radiculopathy, or signs of spinal cord compression. The subacute development

of two or more of these findings should increase suspicion for spinal

epidural abscess. The abscess is best delineated by spine MRI and may

track over multiple spinal levels.

Lumbar adhesive arachnoiditis with radiculopathy is due to fibrosis

following inflammation within the subarachnoid space. The fibrosis

results in nerve root adhesions and presents as back and leg pain

associated with multifocal motor, sensory, or reflex changes. Causes of

arachnoiditis include multiple lumbar operations (most common in the

United States), chronic spinal infections (especially tuberculosis in the

developing world), spinal cord injury, intrathecal hemorrhage, myelography (rare), intrathecal injections (glucocorticoids, anesthetics, or

other agents), and foreign bodies. The MRI shows clumped nerve

roots on axial views or loculations of cerebrospinal fluid within the

thecal sac. Clumped nerve roots should be distinguished from enlarged

nerve roots seen with demyelinating polyneuropathy or neoplastic

infiltration. Treatment is usually unsatisfactory. Microsurgical lysis of

adhesions, dorsal rhizotomy, dorsal root ganglionectomy, and epidural

glucocorticoids have been tried, but outcomes have been poor. Dorsal

column stimulation for pain relief has produced varying results.

■ TRAUMA

A patient complaining of back pain and an inability to move the legs

may have a spine fracture or dislocation; fractures above L1 place the

spinal cord at risk for compression. Care must be taken to avoid further

damage to the spinal cord or nerve roots by immobilizing the back

or neck pending the results of radiologic studies. Vertebral fractures

frequently occur in the absence of trauma in association with osteoporosis, glucocorticoid use, osteomyelitis, or neoplastic infiltration.

Sprains and Strains The terms low back sprain, strain, and

mechanically induced muscle spasm refer to minor, self-limited injuries

associated with lifting a heavy object, a fall, or a sudden deceleration

such as in an automobile accident. These terms are used loosely and do

not correlate with specific underlying pathologies. The pain is usually

confined to the lower back. Patients with paraspinal muscle spasm

often assume unusual postures.

Traumatic Vertebral Fractures Most traumatic fractures of

the lumbar vertebral bodies result from injuries producing anterior

wedging or compression. With severe trauma, the patient may sustain

a fracture-dislocation or a “burst” fracture involving the vertebral body

and posterior elements. Traumatic vertebral fractures are caused by

falls from a height, sudden deceleration in an automobile accident, or

direct injury. Neurologic impairment is common, and early surgical

treatment is indicated. In victims of blunt trauma, CT scans of the

chest, abdomen, or pelvis can be reformatted to detect associated vertebral fractures. Rules have been developed to avoid unnecessary spine

imaging associated with low-risk trauma, but these studies typically

exclude patients aged >65 years—a group that can sustain fractures

with minor trauma.

■ METABOLIC CAUSES

Osteoporosis and Osteosclerosis Immobilization, osteomalacia, the postmenopausal state, renal disease, multiple myeloma,

hyperparathyroidism, hyperthyroidism, metastatic carcinoma, or glucocorticoid use may accelerate osteoporosis and weaken the vertebral

body, leading to compression fractures and pain. Up to two-thirds of

compression fractures seen on radiologic imaging are asymptomatic.

The most common nontraumatic vertebral body fractures are due to

a postmenopausal cause, or to osteoporosis in adults >75 years old

(Chap. 411). The risk of an additional vertebral fracture 1 year following a first vertebral fracture is 20%. The presence of fever, weight

loss, fracture at a level above T4, any fracture in a young adult, or the

predisposing conditions described above should increase suspicion

for a cause other than typical osteoporosis. The sole manifestations

of a compression fracture may be localized back or radicular pain

exacerbated by movement and often reproduced by palpation over the

spinous process of the affected vertebra.

Relief of acute pain can often be achieved with acetaminophen,

NSAIDs, opioids, or a combination of these medications. Both pain

and disability are improved with bracing. Antiresorptive drugs are

not recommended in the setting of acute pain but are the preferred

treatment to prevent additional fractures. Less than one-third of

patients with prior compression fractures are adequately treated for

osteoporosis despite the increased risk for future fractures; even fewer

at-risk patients without a history of fracture are adequately treated. The

literature for percutaneous vertebroplasty (PVP) or kyphoplasty for

osteoporotic compression fractures associated with debilitating pain

does not support their use.

124 PART 2 Cardinal Manifestations and Presentation of Diseases

Osteosclerosis, an abnormally increased bone density often due

to Paget’s disease, is readily identifiable on routine x-ray studies and

can sometimes be a source of back pain. It may be associated with

an isolated increase in alkaline phosphatase in an otherwise healthy

older person. Spinal cord or nerve root compression can result from

bony encroachment. The diagnosis of Paget’s disease as the cause of a

patient’s back pain is a diagnosis of exclusion.

For further discussion of these bone disorders, see Chaps. 410,

411, and 412.

■ AUTOIMMUNE INFLAMMATORY ARTHRITIS

Autoimmune inflammatory disease of the spine can present with the

insidious onset of low back, buttock, or neck pain. Examples include

rheumatoid arthritis (RA) (Chap. 358), ankylosing spondylitis, reactive arthritis and psoriatic arthritis (Chap. 355), or inflammatory

bowel disease (Chap. 326).

■ CONGENITAL ANOMALIES OF THE LUMBAR

SPINE

Spondylolysis is a bony defect in the vertebral pars interarticularis (a

segment near the junction of the pedicle with the lamina), a finding present in up to 6% of adolescents. The cause is usually a stress

microfracture in a congenitally abnormal segment. Multislice CT with

multiplanar reformation is the most accurate modality for detecting

spondylolysis in adults. Symptoms may occur in the setting of a single

injury, repeated minor injuries, or during a growth spurt. Spondylolysis

is the most common cause of persistent LBP in adolescents and is often

associated with sports-related activities.

Scoliosis refers to an abnormal curvature in the coronal (lateral)

plane of the spine. With kyphoscoliosis, there is, in addition, a forward

curvature of the spine. The abnormal curvature may be congenital, due

to abnormal spine development, acquired in adulthood due to degenerative spine disease, or progressive due to paraspinal neuromuscular

disease. The deformity can progress until ambulation or pulmonary

function is compromised.

Spina bifida occulta (closed spinal dysraphism) is a failure of closure

of one or several vertebral arches posteriorly; the meninges and spinal

cord are normal. A dimple or small lipoma may overlie the defect, but

the skin is intact. Most cases are asymptomatic and discovered incidentally during a physical examination for back pain.

Tethered cord syndrome usually presents as a progressive cauda

equina disorder (see below), although myelopathy may also be the

initial manifestation. The patient is often a child or young adult who

complains of perineal or perianal pain, sometimes following minor

trauma. MRI studies typically reveal a low-lying conus (below L1 and

L2) and a short and thickened filum terminale. The MRI findings also

occur as incidental findings, sometimes during evaluation of unrelated

LBP in adults.

■ REFERRED PAIN FROM VISCERAL DISEASE

Diseases of the thorax, abdomen, or pelvis may refer pain to the spinal

segment that innervates the diseased organ. Occasionally, back pain

may be the first and only manifestation. Upper abdominal diseases

generally refer pain to the lower thoracic or upper lumbar region

(eighth thoracic to the first and second lumbar vertebrae), lower

abdominal diseases to the midlumbar region (second to fourth lumbar

vertebrae), and pelvic diseases to the sacral region. Local signs (pain

with spine palpation, paraspinal muscle spasm) are absent, and little or

no pain accompanies routine movements.

Low Thoracic or Lumbar Pain with Abdominal Disease Tumors

of the posterior wall of the stomach or duodenum typically produce

epigastric pain (Chaps. 80 and 324), but back pain may occur if retroperitoneal extension is present. Fatty foods occasionally induce back pain

associated with biliary or pancreatic disease. Pathology in retroperitoneal

structures (hemorrhage, tumors, and pyelonephritis) can produce paraspinal pain that radiates to the lower abdomen, groin, or anterior thighs. A

mass in the iliopsoas region can produce unilateral lumbar pain with radiation toward the groin, labia, or testicle. The sudden appearance of lumbar

pain in a patient receiving anticoagulants should prompt consideration of

retroperitoneal hemorrhage.

Isolated LBP occurs in some patients with a contained rupture of

an AAA. The classic clinical triad of abdominal pain, shock, and back

pain occurs in <20% of patients. The diagnosis may be missed because

the symptoms and signs can be nonspecific. Misdiagnoses include

nonspecific back pain, diverticulitis, renal colic, sepsis, and myocardial infarction. A careful abdominal examination revealing a pulsatile

mass (present in 50–75% of patients) is an important physical finding.

Patients with suspected AAA should be evaluated with abdominal

ultrasound, CT, or MRI (Chap. 280).

Sacral Pain with Gynecologic and Urologic Disease Pelvic

organs rarely cause isolated LBP. Uterine malposition (retroversion,

descensus, and prolapse) may cause traction on the uterosacral ligament.

The pain is referred to the sacral region, sometimes appearing after

prolonged standing. Endometriosis or uterine cancers can invade the

uterosacral ligaments. Pain associated with endometriosis is typically

premenstrual and often continues until it merges with menstrual pain.

Menstrual pain with poorly localized, cramping pain can radiate

down the legs. LBP that radiates into one or both thighs is common

in the last weeks of pregnancy. Continuous and worsening pain unrelieved by rest or at night may be due to neoplastic infiltration of nerves

or nerve roots.

Urologic sources of lumbosacral back pain include chronic prostatitis, prostate cancer with spinal metastasis (Chap. 87), and diseases of

the kidney or ureter. Infectious, inflammatory, or neoplastic renal diseases may produce ipsilateral lumbosacral pain, as can renal artery or

vein thrombosis. Paraspinal lumbar pain may be a symptom of ureteral

obstruction due to nephrolithiasis.

■ OTHER CAUSES OF BACK PAIN

Postural Back Pain There is a group of patients with nonspecific

chronic low back pain (CLBP) in whom no specific anatomic lesion can

be found despite exhaustive investigation. Exercises to strengthen the

paraspinal and abdominal muscles are sometimes helpful. CLBP may

be encountered in patients who seek financial compensation; in malingerers; or in those with concurrent substance abuse. Many patients

with CLBP have a history of psychiatric illness (depression, anxiety

states) or childhood trauma (physical or sexual abuse) that antedates

the onset of back pain. Preoperative psychological assessment has been

used to exclude patients with marked psychological impairments that

predict a poor surgical outcome from spine surgery.

Idiopathic The cause of LBP occasionally remains unclear. Some

patients have had multiple operations for disk disease. The original

indications for surgery may have been questionable, with back pain

only, no definite neurologic signs, or a minor disk bulge noted on CT

or MRI. Scoring systems based on neurologic signs, psychological

factors, physiologic studies, and imaging studies have been devised to

minimize the likelihood of unsuccessful surgery.

■ GLOBAL CONSIDERATIONS

While many of the history and examination features described in this

chapter apply to all patients, information regarding the global epidemiology and prevalence of LBP is limited. The Global Burden of Diseases

Study 2019 reported that LBP represented the #1 cause overall for total

years lived with disability (YLD), and #9 overall as a cause of disabilityrelated life years (DALYs). These numbers increased substantially from

1990 estimates, and with the aging of the population worldwide, the

numbers of individuals suffering from LBP are expected to increase

further in the future. Although rankings for LBP generally were higher

in developed regions, a high burden exists in every part of the world.

An area of uncertainty is the degree to which regional differences exist

in terms of the specific etiologies of LBP and how these are managed.

For example, the most common cause of arachnoiditis in developing

countries is a prior spinal infection, but in developed countries the

most frequent cause is multiple lumbar spine surgeries.

125Back and Neck Pain CHAPTER 17

TREATMENT

Back Pain

Management is considered separately for acute and chronic low

back pain syndromes without radiculopathy, and for back pain with

radiculopathy.

ACUTE LOW BACK PAIN WITHOUT RADICULOPATHY

This is defined as pain of <12 weeks duration. Full recovery can

be expected in >85% of adults with ALBP without leg pain. Most

have purely “mechanical” symptoms (i.e., pain that is aggravated by

motion and relieved by rest).

The initial assessment is focused on excluding serious causes

of spine pathology that require urgent intervention, including

infection, cancer, or trauma. Risk factors for a serious cause of

ALBP are shown in Table 17-1. Laboratory and imaging studies are

unnecessary if risk factors are absent. CT, MRI, or plain spine films

are rarely indicated in the first month of symptoms unless a spine

fracture, tumor, or infection is suspected.

The prognosis of ALBP is generally excellent; however, episodes

tend to recur, and as many as two-thirds of patients will experience

a second episode within 1 year. Most patients do not seek medical

care and improve on their own. Even among those seen in primary

care, two-thirds report substantial improvement after 7 weeks. This

high likelihood of spontaneous improvement can mislead clinicians

and patients about the efficacy of treatment interventions, highlighting the importance of rigorous prospective trials. Many treatments commonly used in the past are now known to be ineffective,

including bed rest and lumbar traction.

Clinicians should reassure and educate patients that improvement is very likely and instruct them in self-care. Satisfaction and

the likelihood of follow-up increase when patients are educated

about prognosis, evidence-based treatments, appropriate activity modifications, and strategies to prevent future exacerbations.

Counseling patients about the risks of overtreatment is another

important part of the discussion. Patients who report that they did

not receive an adequate explanation for their symptoms are likely to

request further diagnostic tests.

In general, bed rest should be avoided for relief of severe symptoms or limited to a day or two at most. Several randomized trials

suggest that bed rest does not hasten the pace of recovery. In general, early resumption of normal daily physical activity should be

encouraged, avoiding only strenuous manual labor. Advantages of

early ambulation for ALBP also include maintenance of cardiovascular conditioning; improved bone, cartilage, and muscle strength;

and increased endorphin levels. Specific back exercises or early vigorous exercise have not shown benefits for acute back pain. Empiric

use of heating pads or blankets is sometimes helpful.

NSAIDs and Acetaminophen Evidence-based guidelines recommend over-the-counter medicines such as NSAIDs and acetaminophen as first-line options for treatment of ALBP. In otherwise

healthy patients, a trial of NSAIDs can be followed by acetaminophen for time-limited periods. In theory, the anti-inflammatory

effects of NSAIDs might provide an advantage over acetaminophen

to suppress inflammation that accompanies many causes of ALBP,

but in practice there is no clinical evidence to support the superiority of NSAIDs. The risk of renal and gastrointestinal toxicity with

NSAIDs is increased in patients with preexisting medical comorbidities (e.g., renal insufficiency, cirrhosis, prior gastrointestinal

hemorrhage, use of anticoagulants or glucocorticoids, heart failure).

Some patients elect to take acetaminophen and an NSAID together

in hopes of a more rapid benefit.

Muscle Relaxants Skeletal muscle relaxants, such as cyclobenzaprine or methocarbamol, may be useful, but sedation is a common side effect. Limiting the use of muscle relaxants to nighttime

only may be an option for patients with back pain that interferes

with sleep.

Opioids There is no good evidence to support the use of opioid

analgesics or tramadol as first-line therapy for ALBP. Their use is

best reserved for patients who cannot tolerate acetaminophen or

NSAIDs and for those with severe refractory pain. Also, the duration

of opioid treatment for ALBP should be strictly limited to 3–7 days.

As with muscle relaxants, these drugs are often sedating, so it may

be useful to prescribe them at nighttime only. Side effects of shortterm opioid use include nausea, constipation, and pruritus; risks

of long-term opioid use include hypersensitivity to pain, hypogonadism, and dependency. Falls, fractures, driving accidents, and

fecal impaction are other risks. The clinical efficacy of opioids for

chronic pain beyond 16 weeks of use is unproven.

Mounting evidence of morbidity from long-term opioid therapy

(including overdose, dependency, addiction, falls, fractures, accident risk, and sexual dysfunction) has prompted efforts to reduce its

use for chronic pain, including back pain (Chap. 13). When used,

safety may be improved with automated notices for high doses,

early refills, prescriptions from multiple pharmacies, overlapping

opioid and benzodiazepine prescriptions, and in the United States

by state-based prescription drug monitoring programs (PDMPs).

A recent study indicated that most patients with opioid use disorder presenting to emergency departments had no prescriptions

recorded in the PDMP, reflecting other methods used to obtain

opioids. Greater access to alternative treatments for chronic pain,

such as tailored exercise programs and cognitive behavioral therapy

(CBT), may also reduce opioid prescribing.

Other Approaches There is no evidence to support use of oral or

injected glucocorticoids, antiepileptics, antidepressants, or therapies for neuropathic pain such as gabapentin or herbal therapies.

Commonly used nonpharmacologic treatments for ALBP are also

of unproven benefit, including spinal manipulation, physical therapy, massage, acupuncture, laser therapy, therapeutic ultrasound,

corsets, transcutaneous electrical nerve stimulation (TENS), special

mattresses, or lumbar traction. Although important for chronic

pain, use of back exercises for ALBP are generally not supported

by clinical evidence. There is no convincing evidence regarding the

value of ice or heat applications for ABLP; however, many patients

report temporary symptomatic relief from ice or frozen gel packs

just before sleep, and heat may produce a short-term reduction in

pain after the first week. Patients often report improved satisfaction

with the care that they receive when they actively participate in the

selection of symptomatic approaches.

CHRONIC LOW BACK PAIN WITHOUT RADICULOPATHY

Back pain is considered chronic when the symptoms last >12 weeks; it

accounts for 50% of total back pain costs. Risk factors include obesity, female gender, older age, prior history of back pain, restricted

spinal mobility, pain radiating into a leg, high levels of psychological distress, poor self-rated health, minimal physical activity,

smoking, job dissatisfaction, and widespread pain. In general, the

same treatments that are recommended for ALBP can be useful for

patients with CLBP. In this setting, however, the benefit of opioid

therapy or muscle relaxants is less clear. In general, improved activity tolerance is the primary goal, while pain relief is secondary.

Some observers have raised concerns that CLBP may often be

overtreated. For CLBP without radiculopathy, multiple guidelines

explicitly recommend against use of SSRIs, any type of injection,

TENS, lumbar supports, traction, radiofrequency facet joint denervation, intradiskal electrothermal therapy, or intradiskal radiofrequency thermocoagulation. On the other hand, exercise therapy

and treatment of depression appear to be useful and underused.

Exercise Programs Evidence supports the use of exercise therapy

to alleviate pain symptoms and improve function. Exercise can be

one of the mainstays of treatment for CLBP. Effective regimens have

generally included a combination of core-strengthening exercises,

stretching, and gradually increasing aerobic exercise. A program of

supervised exercise can improve compliance. Supervised intensive

126 PART 2 Cardinal Manifestations and Presentation of Diseases

physical exercise or “work hardening” regimens have been effective

in returning some patients to work, improving walking distance,

and reducing pain. In addition, some forms of yoga have been

evaluated in randomized trials and may be helpful for patients who

are interested.

Intensive multidisciplinary rehabilitation programs can include

daily or frequent physical therapy, exercise, CBT, a workplace evaluation, and other interventions. For patients who have not responded

to other approaches, such programs appear to offer some benefit.

Systematic reviews, however, suggest that the evidence and benefits

are limited.

Nonopioid Medications Medications for CLBP may include short

courses of NSAIDs or acetaminophen. Duloxetine is approved for

the treatment of CLBP (60 mg daily) and may also treat coincident

depression. Tricyclic antidepressants can provide modest pain relief

for some patients without evidence of depression. Depression is

common among patients with chronic pain and should be appropriately treated.

Cognitive Behavioral Therapy CBT is based on evidence that

psychological and social factors, as well as somatic pathology, are

important in the genesis of chronic pain and disability; CBT focuses

on efforts to identify and modify patients’ thinking about their condition. In one randomized trial, CBT reduced disability and pain in

patients with CLBP. Such behavioral treatments appear to provide

benefits similar in magnitude to exercise therapy.

Complementary Medicine Back pain is the most frequent reason for seeking complementary and alternative treatments. Spinal

manipulation or massage therapy may provide short-term relief, but

long-term benefit is unproven. Biofeedback has not been studied

rigorously. There is no convincing evidence that either TENS, laser

therapy, or ultrasound are effective in treating CLBP. Rigorous trials of acupuncture suggest that true acupuncture is not superior to

sham acupuncture, but that both may offer an advantage over routine care. Whether this is due entirely to placebo effects provided

even by sham acupuncture is uncertain.

Injections and Other Interventions Various injections, including

epidural glucocorticoid injections, facet joint injections, and trigger

point injections, have been used for treating CLBP. However, in

the absence of radiculopathy, there is no clear evidence that these

approaches are sustainably effective.

Injection studies are sometimes used diagnostically to help determine the anatomic source of back pain. Pain relief following a glucocorticoid and anesthetic injection into a facet or medial branch block

are used as evidence that the facet joint is the pain source; however,

the possibility that the response was a placebo effect or due to systemic absorption of the glucocorticoids is difficult to exclude.

Another category of intervention for CLBP is electrothermal

and radiofrequency therapy. Intradiskal therapy has been proposed

using energy to thermocoagulate and destroy nerves in the intervertebral disk, using specially designed catheters or electrodes.

Current evidence does not support the use of discography to

identify a specific disk as the pain source, or the use of intradiskal

electrothermal or radiofrequency therapy for CLBP.

Radiofrequency denervation is sometimes used to destroy nerves

that are thought to mediate pain, and this technique has been used

for facet joint pain (with the target nerve being the medial branch

of the primary dorsal ramus), for back pain thought to arise from

the intervertebral disk (ramus communicans), and radicular back

pain (dorsal root ganglia). These interventional therapies have not

been studied in sufficient detail to draw firm conclusions regarding

their value for CLBP.

Surgery Surgical intervention for CLBP without radiculopathy

has been evaluated in a number of randomized trials. The case

for fusion surgery for CLBP without radiculopathy is weak. While

some studies have shown modest benefit, there has been no benefit

when compared to an active medical treatment arm, often including

highly structured, rigorous rehabilitation combined with CBT. The

use of bone matrix protein (BMP) instead of iliac crest graft for the

fusion was shown to increase hospital costs and length of stay but

not improve clinical outcomes.

Guidelines suggest that referral for an opinion on spinal fusion

can be considered for patients who have completed an optimal

nonsurgical treatment program (including combined physical and

psychological treatment) and who have persistent severe back pain

for which they would consider surgery. The high cost, wide geographic variations, and rapidly increasing rates of spinal fusion surgery have prompted scrutiny regarding the lack of standardization

of appropriate indications. Some insurance carriers have begun to

limit coverage for the most controversial indications, such as LBP

without radiculopathy.

Lumbar disk replacement with prosthetic disks is US Food and

Drug Administration–approved for uncomplicated patients needing single-level surgery at the L3-S1 levels. The disks are generally

designed as metal plates with a polyethylene cushion sandwiched

in between. The trials that led to approval of these devices were not

blinded. When compared to spinal fusion, the artificial disks were

“not inferior.” Long-term follow-up is needed to determine device failure rates over time. Serious complications are somewhat more likely

with the artificial disk. This treatment remains controversial for CLBP.

LOW BACK PAIN WITH RADICULOPATHY

A common cause of back pain with radiculopathy is a herniated

disk affecting the nerve root and producing back pain with radiation down the leg. The term sciatica is used when the leg pain

radiates posteriorly in a sciatic or L5/S1 distribution. The prognosis

for acute low back and leg pain with radiculopathy due to disk

herniation is generally favorable, with most patients showing substantial improvement over months. Serial imaging studies suggest

spontaneous regression of the herniated portion of the disk in twothirds of patients over 6 months. Nonetheless, several important

treatment options provide symptomatic relief while the healing

process unfolds.

Resumption of normal activity is recommended. Randomized

trial evidence suggests that bed rest is ineffective for treating sciatica as well as back pain alone. Acetaminophen and NSAIDs are useful for pain relief, although severe pain may require short courses

(3–7 days) of opioid analgesics. Opioids are superior for acute pain

relief in the emergency department.

Epidural glucocorticoid injections have a role in providing symptom relief for acute lumbar radiculopathy due to a herniated disk,

but do not reduce the use of subsequent surgical intervention. A

brief course of high-dose oral glucocorticoids (methylprednisolone

dose pack) for 3 days followed by a rapid taper over 4 more days can

be helpful for some patients with acute disk-related radiculopathy,

although this specific regimen has not been studied rigorously.

Diagnostic nerve root blocks have been advocated to determine

if pain originates from a specific nerve root. However, improvement

may result even when the nerve root is not responsible for the pain;

this may occur as a placebo effect, from a pain-generating lesion

located distally along the peripheral nerve, or from effects of systemic absorption.

Urgent surgery is recommended for patients who have evidence

of CES or spinal cord compression, generally manifesting as combinations of bowel or bladder dysfunction, diminished sensation in

a saddle distribution, a sensory level on the trunk, and bilateral leg

weakness or spasticity. Surgical intervention is also indicated for

patients with progressive motor weakness due to nerve root injury

demonstrated on clinical examination or EMG.

Surgery is also an important option for patients who have

disabling radicular pain despite optimal conservative treatment.

Because patients with a herniated disk and sciatica generally experience rapid improvement over weeks, most experts do not recommend considering surgery unless the patient has failed to respond to

a minimum of 6–8 weeks of nonsurgical management. For patients

who have not improved, randomized trials show that surgery results

in more rapid pain relief than nonsurgical treatment. However, after

127Back and Neck Pain CHAPTER 17

2 years of follow-up, patients appear to have similar pain relief and

functional improvement with or without surgery. Thus, both treatment approaches are reasonable, and patient preferences and needs

(e.g., rapid return to employment) strongly influence decisionmaking. Some patients will want the fastest possible relief and find

surgical risks acceptable. Others will be more risk-averse and more

tolerant of symptoms and will choose watchful waiting, especially if

they understand that improvement is likely in the end.

The usual surgical procedure is a partial hemilaminectomy with

excision of the prolapsed disk (diskectomy). Minimally invasive

techniques have gained in popularity in recent years, but some

evidence suggests they may be less effective than standard surgical

techniques, with more residual back pain, leg pain, and higher rates

of rehospitalization. Fusion of the involved lumbar segments should

be considered only if significant spinal instability is present (i.e.,

degenerative spondylolisthesis). The costs associated with lumbar

interbody fusion have increased dramatically in recent years. There

are no large prospective, randomized trials comparing fusion to

other types of surgical intervention. In one study, patients with

persistent LBP despite an initial diskectomy fared no better with

spine fusion than with a conservative regimen of cognitive intervention and exercise. Artificial disks, as discussed above, are used

in Europe; their utility remains controversial in the United States.

PAIN IN THE NECK AND SHOULDER

Neck pain, which usually arises from diseases of the cervical spine and

soft tissues of the neck, is common, typically precipitated by movement, and may be accompanied by focal tenderness and limitation

of motion. Many of the earlier comments made regarding causes of

LBP also apply to disorders of the cervical spine. The text below will

emphasize differences. Pain arising from the brachial plexus, shoulder,

or peripheral nerves can be confused with cervical spine disease

(Table 17-4), but the history and examination usually identify a

more distal origin for the pain. When the site of nerve tissue injury is

unclear, EMG studies can localize the lesion. Cervical spine trauma,

disk disease, or spondylosis with intervertebral foraminal narrowing

may be asymptomatic or painful and can produce a myelopathy, radiculopathy, or both. The same risk factors for serious causes of LBP also

apply to neck pain with the additional feature 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 involvement of the cervical spinal cord.

■ TRAUMA TO THE CERVICAL SPINE

Trauma (fractures, subluxation) places the spinal cord at risk for compression. Motor vehicle accidents, violent crimes, or falls account for

87% of cervical spinal cord injuries (Chap. 442). Immediate immobilization of the neck is essential to minimize further spinal cord injury

from movement of unstable cervical spine segments. A CT scan is the

diagnostic procedure of choice for detection of acute fractures following severe trauma; plain x-rays are used for lesser degrees of trauma

or in settings where CT is unavailable. When traumatic injury to the

vertebral arteries or cervical spinal cord is suspected, visualization by

MRI with magnetic resonance angiography is preferred.

The decision to obtain imaging should be based on the clinical

context of the injury. The National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria established that normally alert

patients without palpation tenderness in the midline; intoxication;

neurologic deficits; or painful distracting injuries were very unlikely to

have sustained a clinically significant traumatic injury to the cervical

spine. The Canadian C-spine rule recommends that imaging should

be obtained following neck region trauma if the patient is >65 years

old or has limb paresthesias or if there was a dangerous mechanism

for the injury (e.g., bicycle collision with tree or parked car, fall from

height >3 ft or five stairs, diving accident). These guidelines are helpful

but must be tailored to individual circumstances; for example, patients

with advanced osteoporosis, glucocorticoid use, or cancer may warrant

imaging after even mild trauma.

Whiplash injury is due to rapid flexion and extension of the neck,

usually from automobile accidents. The likely mechanism involves

injury to the facet joints. This diagnosis should not be applied to

patients with fractures, disk herniation, head injury, focal neurologic

findings, or altered consciousness. Up to 50% of persons reporting

whiplash injury acutely have persistent neck pain 1 year later. When

personal compensation for pain and suffering was removed from the

Australian health care system, the prognosis for recovery at 1 year

improved. Imaging of the cervical spine is not cost-effective acutely but

is useful to detect disk herniations when symptoms persist for >6 weeks

following the injury. Severe initial symptoms have been associated with

a poor long-term outcome.

■ CERVICAL DISK DISEASE

Degenerative cervical disk disease is very common and usually asymptomatic. Herniation of a lower cervical disk is a common cause of pain

or tingling in the neck, shoulder, arm, or hand. Neck pain, stiffness,

and a range of motion limited by pain are the usual manifestations.

TABLE 17-4 Cervical Radiculopathy: Neurologic Features

CERVICAL

NERVE ROOT 

EXAMINATION FINDINGS

REFLEX SENSORY MOTOR PAIN DISTRIBUTION 

C5 Biceps Lateral deltoid Rhomboidsa

 (elbow extends backward with hand on

hip)

Lateral arm, medial scapula

Infraspinatusa

 (arm rotates externally with elbow flexed

at the side)

Deltoida

 (arm raised laterally 30°–45° from the side)

C6 Biceps Palmar thumb/index finger Bicepsa

 (arm flexed at the elbow in supination) Lateral forearm, thumb/index fingers

Dorsal hand/lateral forearm Pronator teres (forearm pronated)

C7 Triceps Middle finger Tricepsa

 (forearm extension, flexed at elbow) Posterior arm, dorsal forearm, dorsal

hand

Dorsal forearm Wrist/finger extensorsa

C8 Finger flexors Palmar surface of little finger Abductor pollicis brevis (abduction of thumb) Fourth and fifth fingers, medial hand

and forearm

Medial hand and forearm First dorsal interosseous (abduction of index finger)

Abductor digiti minimi (abduction of little finger)

T1 Finger flexors Axilla, medial arm, anteromedial

forearm

Abductor pollicis brevis (abduction of thumb) Medial arm, axilla

First dorsal interosseous (abduction of index finger)

Abductor digiti minimi (abduction of little finger)

a

These muscles receive the majority of innervation from this root.