Back and Neck Pain

Question 1

Local pain

Answer 1

Pain localizes to a specific place in the back

Causes: Fractures, tears, stretching of pain-sensitive structures

Question 2

Referred pain

Answer 2

Pain originates from a visceral organ and is referred to the back

Causes: AAA, pancreatitis, renal calculi, perforated peptic ulcer

Question 3

Radicular back pain

Answer 3

Sharp, radiating into the dermatomal distribution of a dermatomal distribution of a nerve root. Made worse with any Valsalva maneuver

Causes: Herniated lumbar disc, degenerative joint disease at the intervertebral foramen, epidural disease

Question 4

Muscle spasms

Answer 4

Painful spasms in the paravertebral muscles. Usually paroxysmal

Causes: Usually of unclear origin

Question 5

Red flags for possible serious underlying process.

Answer 5

These patients should be imaged

1) Age over 50
2) History of cancer
3) Pain for more than a month
4) No relief even with bedrest
5) Bowel or bladder incontinence
6) Focal leg weakness or numbness
7) Glucocorticoid or IV drug use
8) Current systemic infection
9) Unexplained fever or weight loss
10) Reproducible percussion tenderness over the spine
11) CVA tenderness

Question 6

L2 lumbosacral radiculopathy

Answer 6

Reflex - none

Sensation - upper anterior thigh

Weakness - iliopsoas

Pain - Anterior thigh

Question 7

L3 radiculopathy

Answer 7

Reflex - None

Sensation - Anterior knee

Weakness - Iliopsoas, Quads, Hip adductors

Pain - Anterior knee

Question 8

L4 radiculopathy

Answer 8

Reflex - Patellar

Sensation - Medial calf

Weakness - Quads, Tibialis anterior

Pain - Medial calf

Question 9

L5 radiculopathy

Answer 9

Reflex - none

Sensation - Dorsomedial surface of foot, lateral calf

Weakness - Peronei, tibialis anterior, extensor hallicus

Pain - Lateral calf, dorsomedial foot, buttocks/posterior thigh

Question 10

S1 radiculopathy

Answer 10

Reflex - Achilles

Sensation - Plantar and lateral surfaces of the foot

Weakness - Gastrocnemius, Soleus, Gluteus maximus

Pain - Plantar and lateral foot, buttocks/posterior thigh

Question 11

C5 radiculopathy

Answer 11

Reflex - Biceps

Sensations - Shoulder, thumb

Weakness - Deltoid, biceps

Pain - Medial scapula, lateral arm

Question 12

C6 radiculopathy

Answer 12

Reflex - Biceps

Sensations - thumb, index finger, radial hand, lateral forearm

Weakness - Biceps, pronator teres

Pain - Lateral forearm, first 2 digits

Question 13

C7 radiculopathy

Answer 13

Reflex - Triceps

Sensation - Middle digits, posterior forearm

Weakness - triceps, wrist extensors, finger extensors

Pain - Posterior arm and forearm, middle digits

Question 14

C8 radiculopathy

Answer 14

Reflex - Finger flexors

Sensation - fifth digit, medial hand, medial forearm

Weakness - Intrinsic hand muscles

Pain - Last 2 digits, medial forearm

Question 15

T1 radiculopathy

Answer 15

Reflex - Finger flexors

Sensation - medial arm, axilla

Weakness - intrinsic hand muscles

Pain - medial arm, axilla

Question 16

Lumbosacral sprain

Answer 16

Confined to lower back with no radiation or neuro deficits. Paraspinal muscle spasms cause patients to assume unusual postures. Usually post-traumatic

Workup: None needed

Tx: Encourage light exercise and return to normal activity. Consider PT referral. Prescribe NSAIDs or acetaminophen. Use opioids and muscle relaxants carefully

Question 17

Vertebral fracture

Answer 17

Caused by trauma, osteoporosis or vertebral tumor. Persistent local pain with overlying paraspinal muscle spasm. Neuro deficit from radiculopathy may be present

Workup: Plain radiographs initially. Bone scan or MRI if pathologic fracture from tumor suspected

Tx: Ensure adequate pain control. Ortho consult. May be candidate for kyphoplasty

Question 18

Lumbar disc disease

Answer 18

Presents with limitation of spine flexion and radiculopathic features. Most common at L4-L5 and L5-S1. Exacerbated by Valsalva

Workup: If no red flags, may manage conservatively for one month. MRI is the best diagnostic test. Note that many patients with no back pain have herniated disks on MRI

Tx: See lumbosacral strain. Surgery indicated for progressive motor weakness, abnormal bowel or bladder function and incapacitating radicular pain with MRI correlation

Question 19

Spinal stenosis

Answer 19

Caused by a narrowed spinal cord. Back and bilateral leg pain provoked by standing or walking, known as pseudoclaudication. Usually relieved by sitting.

Workup: MRI is most sensitive

Tx: Conservative treatment with NSAIDs, other pain relievers and PT. Surgical management when pain is incapacitating or severe focal deficits develop

Question 20

Spondylosis

Answer 20

Pain usually caused by osteophytes which may compress nerve roots. Pain centered in the spine increased by motion. associated with limitation of motion

Workup: Plain films will show osteophytes and can suggest whether there is narrowing of the intervertebral foramen. MRI and CT more sensitive

Tx: Conservative treatment with NSAIDs, other pain relievers and PT. Surg when pain is incapacitating or severe focal deficits develop

Question 21

Neoplasm

Answer 21

Back pain is a common neuro complaint in cancer patients and may herald a diagnosis. The pain is usually constant, dull, unrelieved by rest and worse at night.

Workup: MRI is the most sensitive study for evaluating epidural disease and vertebral mets. Bone scan and CT also play a role.

Tx: Intractable pain from vertebral mets may respond to radiation depending on tumor type. Neuro deficits from epidural disease demand radiation or surgery

Question 22

Infection

Answer 22

Epidural abscess presents with fever and back pain aggravated by palpation or movement. Vertebral osteomyelitis may not present with fever.

Workup: MRI

Tx: ABx and surgical management are usually combined