Acute pain in the back or neck is one of the most common symptoms experienced by older adults. Virtually every adult has experienced at least one episode of acute spinal pain. For most of these patients, extensive laboratory investigation and imaging tests are unnecessary; rapid improvement can be expected with only simple treatment measures. It should be emphasized, however, that a few patients have significant neurologic impairment or evidence of cancer or other serious underlying systemic illness. For these patients, an extensive differential diagnosis must be considered, and prompt workup and specialty consultation may be necessary.
DIFFERENTIAL DIAGNOSIS AND INITIAL ASSESSMENT
Primary care practitioners often do the initial evaluation and management of patients with acute backrelated symptoms. The initial patient examination may be performed at the physician’s office or in the hospital emergency department. A thorough clinical assessment is crucial to make the best decisions about diagnosis, laboratory testing, diagnostic imaging, and specialist referral. Usually, acute low back or neck pain resolves quickly, and a precise anatomic basis for the pain is never determined. These cases can be referred to as “uncomplicated” low back or neck pain. A nonspecific diagnosis such as lumbar or cervical strain is appropriate.
The clinical approach is quite different for patients with severe or persistent pain (5). In these cases, an extensive differential diagnosis must be considered (Tables 15-1 and 15-2). There are several “red flags” that may indicate the presence of a serious underlying disease. These include severe trauma (for example, motor vehicle accident or sports injury), severe or progressive neurologic deficit, unrelenting nocturnal pain, unexplained weight loss, history of cancer, and fever (Table 15-3). These can be considered to be indicators of “complicated” low back or neck pain.
Table 15-1.Differential Diagnosis of Low Back Pain with or without Radiculopathy
1.
Discogenic or degenerative disease
A.
Herniated intervertebral disk
B.
Degenerative lumbar spondylosis
-Central lumbar canal stenosis
-Lateral recess stenosis
C.
Synovial cyst of facet joint
2.
Tumor
A.
Primary intradural tumor of spinal cord, conus, or cauda equina
B.
Tumor of vertebral column or epidural space (or both)
-Metastatic tumor
-Plasmacytoma or multiple myeloma
-Primary bone tumor (e.g., chordoma)
C.
Extraspinal retroperitoneal malignancy
3.
Vascular lesion
A.
Arteriovenous malformation of the spinal cord
B.
Spinal dural arteriovenous fistula
4.
Infection
A.
Intervertebral diskitis or osteomyelitis
B.
Epidural abscess
C.
Urinary tract infection
D.
Herpes zoster or other viral radiculopathy
5.
Intra-abdominal or intrapelvic disease
A.
Abdominal aortic aneurysm
B.
Nephrolithiasis
C.
Posterior perforating duodenal ulcer
D.
Pancreatic disease
E.
Endometriosis
6.
Degenerative hip disease
7.
Neurologic complications of diabetes
A.
Peripheral neuropathy
B.
Radiculopathy
8.
Congenital
A.
Tethered cord
B.
Intraspinal lipoma
9.
Metabolic bone disease
A.
Osteoporotic compression fracture
10.
Trauma
Table 15-2.Differential Diagnosis of Neck Pain with or without Neurologic Involvement
1.
Discogenic or degenerative disease
A.
Herniated intervertebral disk
B.
Degenerative cervical spondylosis with canal stenosis
C.
Synovial cyst of facet joint
2.
Tumor
A.
Primary intradural tumor of spinal cord or adjacent nerve roots
B.
Tumor of vertebral column or epidural space (or both)
-Metastatic tumor
-Plasmacytoma or multiple myeloma
-Primary bone tumor (e.g., chordoma)
3.
Vascular lesion
A.
Arteriovenous malformation of the spinal cord
B.
Spinal dural arteriovenous fistula
4.
Infection
A.
Intervertebral diskitis or osteomyelitis
B.
Epidural abscess
C.
Herpes zoster or other viral radiculopathy
5.
Degenerative shoulder disease
6.
Neurologic complications of diabetes
7.
Metabolic bone disease
A.
Osteoporotic compression fracture
8.
Trauma
The presence of severe, unremitting pain, especially at night, may indicate the presence of a spinal tumor. This is especially true in the older adult. Any patient over age 65 with acute, severe pain at any level of the spinal column should be considered to have a spinal metastatic tumor until proven otherwise. This suspicion is heightened if the patient has a history of malignant disease or unexplained weight loss. The clinician should also be aware that low back pain may be a referred symptom and may indicate the presence of a serious disease of the abdomen or pelvis, such as abdominal aortic aneurysm, renal colic, pancreatitis, or retroperitoneal tumor. Low back pain may also be a manifestation of urinary tract infection, especially in women. This relatively common problem must be excluded, or treated if present, before embarking on an extensive spinal evaluation.
Table 15-3.Indicators of Complicated Spinal Pain
1.
Severe trauma—for example, motor vehicle accident or serious sports injury
2.
Severe or progressive neurologic deficit
A. Loss of motor strength
B. Numbness or loss of sensation
C. Impaired bladder or bowel control
3.
Unrelenting nocturnal pain
4.
Unexplained weight loss (>4.5 kg in 6 months)
5.
History of cancer
6.
Fever
Patients with low back pain may also have leg pain, often referred to as sciatica or radiculopathy. These terms refer to pain and paresthesias extending down the leg in a dermatomal pattern. The onset may be gradual or abrupt, and patients generally do not recall any trauma or unaccustomed physical activity. The most common cause of sciatica is a herniated lumbar intervertebral disk. In the general population, 95% of lumbar disk herniations occur at the L4-5 and L5-S1 levels. In older individuals, upper lumbar disk herniations at or above the L3-4 level are somewhat more common. Other compressive lesions that can cause sciatica include degenerative lumbar spinal stenosis, tumor, and epidural abscess. The clinician must also be aware of noncompressive causes of leg pain, including radiculopathy due to diabetes and herpes zoster (shingles). Pain in the hip and groin may occasionally indicate the presence of an upper lumbar radiculopathy, but more often it indicates the presence of degenerative hip disease, especially in the older adult.
Patients with disorders of the cervical spine can also have neurologic involvement, including cervical radiculopathy, myelopathy, or a combination of the two. Cervical radiculopathy refers to pain and paresthesias radiating to the arm in a specific dermatomal pattern. Cervical myelopathy refers to symptoms caused by spinal cord compression. These symptoms are more ominous and may include weakness and clumsiness of the arms and legs and bowel and bladder dysfunction.
CLINICAL ASSESSMENT
The importance of a detailed medical history cannot be overemphasized. The patient should be asked to describe the site, duration, and intensity of pain; extension of pain; body positions that relieve or exacerbate the pain; extremity weakness or sensory disturbance; and any bladder or bowel dysfunction. Any history of trauma, weight loss, malignant disease, or other systemic disease should be noted. The physician should carefully review the medication history and any other treatments that have been used. It is important to take the time to obtain an accurate and thorough medication history because some patients may obtain prescription and over-the-counter medications from multiple sources. Diet supplements and other “alternative medicine” remedies have become increasingly popular, and the clinician should ask about these as well. The physician should inquire about previous episodes of spinal pain and what treatments have been used.
An accurate history of tobacco use is essential. Smoking is a risk factor for osteoporosis and chronic back pain. Smoking may increase intradiskal pressure because of chronic coughing, jeopardize disk metabolism because of vascular effects of nicotine, and serve as a marker for psychosocial traits associated with frequent and prolonged pain.
Secondary gain phenomena such as litigation, workers compensation issues, job dissatisfaction, psychiatric problems, and narcotic abuse should be completely explored. These psychosocial issues appear to have an important influence in magnifying symptoms of back and neck pain. Waddell et al. (9) have described a group of nonorganic physical signs that are highly suggestive of psychosocial distress, rather than a structural lesion in the spine. These include tenderness that is superficial and nonanatomic, reproduction of low back pain by application of pressure to the top of the head, inconsistent responses to straight-leg raising with distraction, “give way” weakness, nonanatomic sensory findings, and an overreaction to routine examination maneuvers. These signs have withstood the test of time and continue to be very useful in the evaluation of spine patients with psychological overlay.
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Back and Neck Pain
