I. General considerations

A. It is estimated 80% of the general population suffers at least one disabling episode of back or neck pain in their lifetime.

B. The majority recover without sequelae, most without any contact with the health care system.

C. Many patients who do not recover have no clear pathophysiological diagnosis as a basis for continued pain.

D. Advances in medical technology have contributed to increased costs associated with the evaluation and treatment of persistent back or neck pain.

E. It is well established if disability involves litigation (worker’s compensation or personal injury), the outcome is less predictable and the problem is less likely to resolve quickly.

II. Treatment of acute neck or low back pain

A. Must evaluate neurological deficit that may necessitate urgent surgical intervention

B. Diagnostic imaging is rarely necessary for acute episodes when no trauma is involved. (Exception to this is an occupational injury where medicolegal issues may need to be addressed at a later time).

C. Initial goal is pain relief as these patients often experience severe, disabling pain and spasm.

D. Appropriate medication includes nonsteroidal anti-inflammatory drugs (NSAIDs), short-term narcotic analgesics (2 to 4 days only), and muscle relaxants if spasm is a significant physical finding.

E. Nonpharmacological pain-reducing modalities such as heat, ice, rest, positioning, relaxation, and massage

F. Most important early intervention is patient education.

H. Essential components of patient education include

1. Likely causes of current condition based on a discussion of simple anatomy (models or pictures are often helpful)

2. Natural history of injury, including how each element of the treatment plan will facilitate this

3. Benefits of maintaining activity with a brief discussion of specific aggravating activities

4. Instruction on progressive exercise program emphasizing both endurance (cardiovascular conditioning) and strength (isometrics and core stabilization)

5. Once the acute episode has subsided, education on health promotion and lifestyle changes (weight loss, maintenance exercise, smoking cessation, and stress management) may help prevent recurrences or decrease their frequency and severity.

6. Formal physical therapy may be instituted initially or reserved for later if necessary, depending on the individual’s preinjury physical conditioning, motivation, and physical demands of daily activities including job requirements.

III. Rehabilitation of chronic injury

A. General considerations

1. Controversy exists as to when acute pain becomes chronic.

2. Generally accepted that there is lack of progress toward recovery, despite assumed continued tissue healing, and no specific pathophysiological diagnosis

3. Chronic pain involves psychosocial as well as physical components.

4. Goal is to improve function and maximize quality of life, not necessarily eliminate the pain.

B. Functional restoration programs

1. Hallmark is repeated measures of factors related to the injury or disability such as strength, endurance, and coordination.

2. Utilize functional capacity measures as a basis of monitoring progress and goal attainment.

3. Outcomes vary and may be secondarily measured by subscores of improved quality-of-life scales, symptom interference scales, objective strength or endurance measures, and decreased use of medication.

4. Factors found to contribute to poorer outcomes (in terms of return to work only) include high pretreatment self-reported scores for pain, depression, and disability; relatively short work history prior to injury; previous surgical failure; and job dissatisfaction.

5. Patients with chronic neck pain may benefit from similar programs.

6. Formal functional restoration programs should be reserved for carefully selected patients due to high cost and variability of outcomes.

C. Pain centers

1. Multidisciplinary programs generally based on a medical model

3. Incorporates concepts of behavior modification such as biofeedback, stress management, coping strategies, and relaxation techniques

4. May also address occupational issues such workplace modification

5. May be the most appropriate environment for detoxification from narcotics when this is necessary

6. Treatment of chronic pain with invasive methods such as implantable morphine pump, spinal cord stimulator, sympathectomy and rhizotomy, is controversial.

D. Injections for treatment of back and neck pain

1. Medications such as local anesthetics and steroids are injected into various locations within the vertebral column for both diagnostic and therapeutic reasons.

2. Indicated as an adjunct modality for temporary pain relief so that exercises and rehabilitation can ensue

3. May be used in response to a specific diagnosis established by imaging or based on a clinical diagnosis based on history and physical alone

4. Placebo effect is always possible and difficult to prove.

5. Types of therapeutic injections

a. Local trigger point injection can be used in patients with muscular, tendinous, or myofascial pain with marked point tenderness.

b. Epidural steroid is indicated for persistent radiculopathy despite NSAIDs in patients with herniated disk or spinal stenosis.

c. Nerve root block is indicated for diagnosis of foraminal nerve root compression and for relief of radicular symptoms due to foraminal stenosis.

d. Facet joint injection is indicated for symptomatic facet joint pain syndrome.

(1) Most patients should have painful extension and spinal imaging showing facet joint arthritis.

(2) Facet joint syndrome is difficult to diagnose and injection is unpredictable for pain relief.

e. Intradiscal steroid injection is controversial and may be indicated for patients with discogenic back pain.

I. General considerations

A. Physicians are called upon to determine physical impairment to satisfy insurers, employers, and/or government agencies.

B. Impairment ratings are often required in worker’s compensation, personal injury, or applications for social security disability.

C. Definitions

a. Results from a medical condition and can be temporary or permanent

2. Disability is the extent to which a person can continue to function with the impairment considering their occupational demands, training, education, and other psychosocial factors.

3. Whole person refers to the person prior to illness or injury.

a. Describes the person as a sum of all parts (both anatomic and physiological). Impairment is determined by the loss of one part as compared with the whole, thus the term partial disability.

b. The exact implementation of this principle varies state by state.

4. Healing period is defined as the time when progress is being made toward improvement of pain or function and treatment continues.

5. Healing plateau is defined as the time when treatment is maintenance in nature, and further significant changes in status are not anticipated.

II. Determination of disability and impairment

A. Four components for determining impairment and disability

1. Determine causality

a. Self-explanatory, requires an opinion about the relationship between the circumstances that caused the impairment and the resultant impairment itself

2. Apportionment

a. Determine the role of “preexisting conditions” such as degenerative joint disease in determining impairment from an injury.

b. American Medical Association has five types of apportionment.

(1) An occupational disorder aggravated by a supervening occupational disorder

(2) An occupational disorder aggravated by a supervening other occupational condition arising out of or in the course of employment by the same employer

(3) An occupational disorder aggravated by a supervening other occupational condition arising in the course of employment by a different employer

(4) An occupational disorder aggravated by a preexisting nonoccupational condition

(5) An occupational disorder aggravating a preexisting nonoccupational condition

3. Determine end of healing

a. Often an arbitrary period based on the individual clinician’s practice, patient population, local culture, and experience

4. Assign impairment rating

a. May be temporary or permanent

b. Encompasses both residual symptoms as well as permanent restrictions

c. Ultimately should be based on an objective assessment of the patient’s ability to perform certain functional tasks such as sitting, lifting, gripping and pushing

d. Formal evaluation methods are evolving.

III. Spinal impairment rating

A. There are many rating systems available including ones developed by the American Medical Association and the American Academy of Orthopaedic Surgeons.

B. Elements for determining impairment include

1. Range of motion

a. Measured with goniometer or inclinometer

2. Neurological impairment

a. Includes sensory changes, loss of reflex, and loss of motor function (weakness to paralysis)

3. Specific diagnosis or surgical intervention

4. Psychosocial impairment

a. Includes such items as activities of daily living, social functioning, concentration, and coping

C. Clinician will benefit from finding one rating system and using it consistently to become most proficient.

D. Treating physicians must not view impairment ratings as reflections of treatment failure.

Boldin C, Raith J, Fankhauser F, et al. Predicting neurologic recovery in cervical spinal cord injury with postoperative MR imaging. Spine 2006;31:554–559

Fisher CG, Noonan VK, Dvorak MF. Changing face of spine trauma care in North America. Spine 2006;31:S2–S8

Rechtine GR II. Nonoperative management and treatment of spinal injuries. Spine 2006;31:S22–S27