Neurosurgery

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Management of Back & Neck Pain

Introduction 


Back and neck pain affects virtually all of us at some time in our lives, and ranks only behind cold symptoms as a reason for physician visits. Patients with neck and back pain obtain care from primary care specialists, chiropractors, as well as a variety of specialists, including physiatrists, rheumatologists, orthopedic surgeons, and neurosurgeons. With this diversity in outlooks, a systematic and rational early approach to back pain is imperative.

The epidemiological literature suggests that the vast majority of uncomplicated neck pain and low back cases adequately resolve within a 12 week period. However, there is a high recurrence rate which frequently leads to significant costs and personal disability, particularly in the workers' compensation system. Furthermore, a small percentage of the population goes on to develop complex biopsychosocial problems leading to prolonged disability at a disproportionate cost to society. Since the later half of the 1970's, the cost of low back disability has grown approximately 1,400% faster that the rate of population growth.

Therefore, it is extremely important that the managing professional recommend or select treatment that is likely to expedite prompt return to normal activity. Treatment should be provided in a fashion that fosters patient independence with the intent to diminish the possibility of chronicity. Effective patient evaluation should take into consideration not only musculoskeletal/ spinal status but broader systemic and emotional health issues. The primary care/family medical physician is often uniquely capable of assessing both patient and familial needs.

The following synopsis provides a general approach to the assessment of non-mechanical versus mechanical causes of spine pain. It is intended to ease the clinical decision-making process by earmarking "red flags" suggesting more serious pathology. Discussion regarding the ever widening spectrum of "non-operative" treatment is intended to assist the clinical physician in differentiating effective from useless therapies. As always, the SpineCare transdisciplinary team of professionals is available to assist you in any way possible, including patient care and educational programs. Please call us at 414-955-7199.
 


Spine Pain Facts

Low back pain (LBP) is nearly universal among adults in the United States with a lifetime prevalence estimated as high as 90% and an annual incidence of 5%.  Disabling neck pain is seen in almost 80%.  However, acute persistent low back pain is rare in the pediatric population and may herald significant pathology.
 
Only 10 to 20% of patients have a specific anatomic etiology that can be clearly and objectively identified. Non-mechanical "serious" causes of low back pain requiring urgent recognition are rare, representing less than 1% of unselected patients with LBP.

Radiographic "abnormalities" identified on plain X-rays, computerized tomography (CT) scan or magnetic resonance imaging (MRI) are frequently clinically irrelevant. Indeed, we know little of what causes spinal pain, and correction of even obvious structural abnormalities often fail to relieve pain.

True sciatica, defined as radicular symptoms related to appreciable nerve root compression, occur in only 5% of patients presenting with low back pain.
 


Diagnosis

Up to 85% of patients with back and neck pain cannot and perhaps should not be given a definitive diagnosis. As noted earlier, there is a often a poor association between symptoms, pathologic findings and imaging results. The purpose of the initial evaluation is to identify:
 

  1. Serious underlying systemic disease manifesting as back pain
  2. Neurologic deficit which may require surgical evaluation
  3. Significant social or psychological distress that may prolong pain and classify back pain symptoms into certain categories:
A. Potentially serious spinal conditions
B. Radicular back pain
C. Non-specific back pain

A focused history and physical examination can identify pertinent historical red flags, significant neurological deficits and nonorganic physical findings; this can be used to classify back and neck pain symptoms.

Relevant historical information includes the onset, duration, location and severity of pain. Alleviating and aggravating factors such as sitting, standing, walking, bending, lifting, coughing and sneezing should be noted. The impact of symptoms on activity and response to previous therapy are important in the care of back and neck pain problems. Use of instruments, such as a pain drawing or visual analogue scale is often valuable to augment the history.

A focused physical examination is recommended and should include assessment of upper and lower extremity sensation, strength including proximal and distal manual muscle testing and reflexes (biceps, triceps, brachioradialis, patella, Achilles).

Additional tests such as a straight leg raise, spinal range of motion, and palpation are recommended in the assessment of neck/back pain patients.

In addition assessment of gait, peripheral pulses, abdominal, vaginal and rectal examination, breast examination, assessment of hamstring and triceps surae flexibility and Babinski add to the thoroughness of a focused examination and may rule out visceral diseases unrelated to the spine including diseases of the pelvic organs, kidneys, gastrointestinal tract and aorta. Cerebral disorders can mimic spinal problems by causing arm or leg weakness or numbness; helpful distinguishing symptoms and signs include the presence/absence of neck pain/headache, and cranial nerve abnormalities, especially of the facial nerve.
 


Clinical Evaluation to Rule Out Systemic Disease

Clinical evaluation to rule out systemic disease Malignancy is the most worrisome underlying systemic cause of back and neck pain. Even so, cancer accounts for less than 1% of episodes of spinal pain. Metastatic cancer and primary tumors such as multiple myeloma are more common than spinal infections (osteomyelitis, epidural abscess, etc.) or inflammatory conditions such as ankylosing spondylitis. Most spinal infections are blood borne from other sites, such as indwelling urinary catheters, skin infections or injections of "street drugs." About 80% of patients with an underlying malignancy are over age 50.
 

Red Flags

 

History 

Physical Findings

Fever Spine Tenderness to Percussion
Chills Lymphadenopathy
IV Drug Abuse Cachexia
Recent Urinary Tract Infection Skin Erythema
HIV/AIDS Neurologic Deficit
Corticosteroid use, Diabetes  
History of Cancer  
Unexplained Weight Loss  
Increasing Pain  
Nocturnal Pain  
Pain unrelieved by bed rest  
Metabolic Bone Disease  
Vascular Deficit  
Progressive Neurologic Deficit  


Clinical Evaluation for Neurologic Compromise 

Over 90% of disc herniations in the low back occur at either L4-5 or L5-S1 intervertebral levels.  In older individuals, herniations at L3-4 are quite common.  Neurologic exam should address ankle dorsiflexion strength, great toe dorsiflexion strength, knee flexor and hip extensor strength, medial hamstring and ankle reflexes, and sensory examination as these are the most likely deficits seen in patients with L5 or S1 nerve root impairments.

Ipsilateral straight leg raising is a moderately sensitive test for nerve root irritation.  Crossed straight leg raising sign is a highly specific sign for nerve root irritation.

Cauda equina syndrome is an indication for emergent surgical referral.  Urinary retention, saddle anesthesia, lower extremity weakness, decreased anal sphincter tone may be seen in this syndrome.  This, and other surgical indications, are discussed later. 

C5-6 is the most common level of disc herniation in the cervical spine.  Complaints of scapular pain or anterior chest wall pain may be associated with radicular pain/paresthesias and arm weakness.  Evidence of motor loss and gait abnormalities in radiculopathy may indicate spinal cord compression and may be a malignant finding.

Thoracic spine abnormalities (tumor, discs) are rare. Thoracic spinal tenderness, intercostal pain, and myelopathy are often seen.

 

Disc Root Reflex Muscles Sensation
L3-L4 L4 Patellar reflex Anterior tibialis Medial leg and medial foot
L4-L5 L5 None Extensor hallucis longus Lateral leg & dorsum of foot
L5-S1 S1 Achilles reflex Peroneus longus & brevis Lateral foot

 

 



Red Flags

History Physical Findings
Pain increased with cough Positive straight leg raise
Sneeze, Valsalva Crossed straight leg sign
Leg pain> back pain Reflex asymmetry
Numbness, tingling in dermatomal pattern Sensory deficits in dermatomal pattern
Increased pain with sitting, bending, lifting Weakness in myotomal pattern
Severe motor loss, i.e. foot drop Pathological reflexes
Arm pain> neck pain Loss of position sense (long tract signs)

Evaluation of Psychosocial Factors Affecting Back Pain 

Attention to psychological and social economic problems in the individual's life is recommended.  Such non-physical factors can complicate both the assessment and treatment of back pain. Psychosocial stressors including perceived high levels of stress, family or job disharmonies, previous treatment failures, substance abuse and job dissatisfaction can compromise outcome. 

Evidence of psychological distress should be sought during the examination.  A number of features of the history and physical exam which may be markers of psychological distress are noted below: 

Red Flags

History Physical Findings
Non-anatomical pain complaint Superficial tenderness
Nondermatomal numbness Nondermatomal sensory loss
Intolerance of treatments Increased pain with axial loading
Constant pain Increased pain with rotation distraction
Emotional Overt pain behaviors
  SLR improves with distraction

 

 

 

 

 

 

 

 


Criteria for Radiographic Studies

In the past, plain x-rays were routinely ordered for patients with back or neck pain.  However, routine plain x-rays are unnecessary in the majority of patients presenting with initial onset of pain.  Many radiographic anomalies are equally common in symptomatic and asymptomatic persons (single disc space narrowing, facet joint abnormalities, spondylosis, spina bifida occulta). 

In the absence of neurologic deficits, plain radiography is inappropriate for patients with less than 1 week of pain, and of uncertain value for patients with 1 to 7 weeks of pain.

The lumbar obliques are probably unnecessary for the majority of patients needing imaging studies.  The AP and lateral views alone provide substantial information and eliminate two-thirds of the radiation exposure and costs.

Widespread use of CT and MRI has occurred due to the noninvasive properties of these tests, superior resolution compared to myelography and customer demand.  Unfortunately, due to the high sensitivity and low specificity of these diagnostic studies, clinical difficulties frequently arise. Many "normal" individuals frequently have abnormal imaging studies.  Abnormal MRI findings may lead to unnecessary treatment with disappointing results.

Clinical indicators for radiography

  • Significant trauma; evaluate possible fracture
  • Neuromotor deficits; identify underlying spondylolisthesis or malignancy
  • Unexplained weight loss (> 10 pounds in 6 months) or lymphadenopathy
  • Drug or alcohol abuse; increased risk of trauma and osteoporosis
  • History of cancer
  • Fever (temperature greater than 100 degrees Fahrenheit)
  • Long term use of corticosteroids
  • Suspicion of ankylosing spondylitis
  • Failure to improve after 4 to 6 weeks of non-operative therapy 

Back and/or neck pain and age greater than 50 years old alone is not an absolute indication for x-rays.  However, 80% of patients with cancer are over age 50.

Clinical indicators for advanced diagnostic studies

  • Objective neurologic deficits
  • Potential surgical treatment
  • Signs of spinal stenosis
  • Pathological reflexes
  • Cervical spondylolytic myelopathy 
      

Criteria for Laboratory Tests

The only value of laboratory tests is to help rule out underlying systemic disease.  Since systemic illness is a rare cause of back pain, most positive laboratory tests are likely to be false positives. The ESR may be a useful screening test for patients with possible infection or cancer.  Rarely, a CBC, U/A, SPEP, C-reactive protein, thyroid function test, alkaline phosphatase, or uric acid may be indicated.  More rarely, consideration for inflammatory arthropathies may be entertained, including antinuclear antibodies and serum antigens including HLA.B27.  These should almost never be done initially.


Criteria for Electrodiagnostic Studies

EMG/nerve conduction studies may be appropriate in the evaluation of low back and radicular pain at least 6 weeks after the development of symptoms.  Electrodiagnostic studies are complementary to the history, physical examination and radiographic imaging studies.  No physiologic testing is necessary if the diagnosis is obvious on clinical examination and correlates with other nerve radiographic studies.  However, it may be helpful to evaluate vague pain and sensory symptoms, rule out an underlying or superimposed peripheral neuropathy and assist in establishing the level of radicular involvement.
 


Initial Evaluation Recommendations

In the absence of "red flags," no diagnostic studies are indicated in the first 4 to 6 weeks after onset of pain.  At that time, if no improvement is noted, diagnostic studies may be considered.


Treatments

The prognosis for patients with acute back and neck pain is quite favorable.  Recurrences are common but frequently resolve rather rapidly. Initial treatment may include reassurance, patient education, and activity modification.  Manual therapy and physical therapy often are recommended. 
 


Brief Bed Rest

Even though bed rest in the historical mainstay of therapy for acute low back pain, it is probably of no value.  Brief (1 to 2 days) if any bed rest is sufficient.  Multiple studies have demonstrated no differences between speed of pain resolution, functional recovery, or satisfaction with care with 2 days of bed rest versus 7 days of bed rest.  In addition, patients with no or limited bed rest return to their normal activities much sooner.  Lengthy bed rest contributes to deconditioning, with loss of cardiopulmonary and muscle fitness, and may contribute to anxiety, depression, and decreased motivation.
                                                                                                                                                                                                                                                                                                       


Bracing

Neck or back bracing may be occasionally of value for a few days after trauma.  Other than for fracture, there are no indications for longer-term immobilization.  Indeed, this contributes to loss of muscle conditioning and may be harmful over the long term.
 


Reassurance

Back pain is an extremely common condition and has a very favorable prognosis.  The natural history is one of rapid recovery and return to activity.  Reassurance and education regarding the natural history of back pain should occur during the initial evaluation. "Fear of pain ... may be more disabling than pain itself.
 


Medications

The goal of medication is to relieve symptoms, allowing for quick return to functional daily activities.  When choosing a medication, contraindications, efficacy, complications/risks, cost, and patient compliance should be assessed.

Non-steroidal anti-inflammatory drugs (NSAIDS) have anti-inflammatory, analgesic and antipyretic properties.  Their use in acute musculoskeletal injuries is well established.  Several NSAIDS have been shown to be effective in randomized clinical trials (Naprosyn, Diflunisal, and Piroxicam).  Most NSAIDS are probably beneficial but the cost, side-effect profile (especially GI distress) and length of treatment need to be considered.  The differences between agents are in duration of action, degree of side effects, and individual patient tolerance rather than effectiveness. 

Acetaminophen has been shown to relieve pain in osteoarthritis and plays a strong role in the treatment of back pain.  This medication should be a first line drug. 

Use of Ibuprofen plus Acetaminophen is recommended initially for pain relief.  Use of more than one NSAID simultaneously should be avoided.  Allow up to 2 weeks for maximal anti-inflammatory effect. 

Muscle relaxants including Cyclobenzaprine are often prescribed in the acute phase of pain.  Their efficacy over placebos is uncertain; some studies have demonstrated a very slight improvement in ADL function when Cyclobenzaprine and Diflunisal were given together in the acute phase.  Opioids are rarely indicated for treatment of acute neck/back pain.  In acute disc herniations, narcotic pain medication may be necessary but should be limited to up to 3 to 5 days.

Corticosteroids have powerful anti-inflammatory effects.  Side-effects may include hyperglycemia, hypertension, transient adrenal suppression and increase risk of avascular necrosis and infection.  No studies have demonstrated effectiveness of oral steroids alone in the treatment of back pain, and they should rarely be used initially. 
 


Chiropractic Treatment

Utilization studies have shown chiropractic management in up to 40% of occupational back claims.  Early experiences suggest that integration of chiropractic treatment (SMT) into multimodal management improves outcome.

Indications for chiropractic treatment
Spinal manual therapy (SMT) is often indicated in mechanical back or neck syndromes, particularly in the absence of radicular symptoms. It is critical that the referring physician remain informed regarding the patient's response to chiropractic management as well as the frequency and duration of treatment. Referral for chiropractic treatment (SMT) may be considered when:

? Mechanical neck and/or back pain symptoms predominate.
? SMT is integrated into a back stabilization program emphasizing improved strength, flexibility, and cardiovascular fitness.

Contraindications for chiropractic treatment
Certain contraindications to chiropractic treatment have been established. 
A partial list of significant contraindicators includes:

  • Acute lumbar disc herniation with defined, progressive neurologic deficit, particularly motor weakness
  • Cauda equina syndrome
  • Advanced osteopenia, idiopathic osteoporosis, long term 
    steroid therapy, etc.
  • Vertebral basilar insufficiency
  • Metastatic disease
  • Infection
  • Advanced degenerative joint disease involving segmental instability

 


Urgent Surgical Indications

While surgery has a major role in the management of spinal disorders, it is rarely indicated urgently. Instead, most surgical procedures should take place only after a suitable period of non-operative care. 

This includes the treatment of herniated discs.  While they may be sizable and cause excruciating pain, most studies suggest that a significant percentage of patients will get spontaneous relief with only minimal palliative treatment.  This may take place as rapidly as several days; more typically it may take two to three months.  One study has shown that patients have the same outcome at one year whether or not they are treated surgically; others have shown that at six months and one year, surgery is superior.  It is often hard to convince a patient with excruciating sciatica that removal of an obvious lesion is not necessarily in his/her best interest.  Again, studies further show that sequestered discs will often spontaneously re-absorb.

Therefore, patients need not be referred for surgical treatment for the first several weeks after development of sciatica with some very important exceptions.  One of these is neurological motor deficit.  While minor foot weakness is common and is acceptable following disc herniation, foot drop is not.  Indeed, the latter is often a neurosurgical emergency.

Other surgical emergencies related to disc herniation, but less common, include significant bilateral radiculopathy.  This implies a midline disc herniation which may involve not only the nerves going to the legs, but also may adversely affect bowel and bladder function.  If bowel and bladder abnormalities occur, they often do not improve.  Therefore, central lumbar disc herniations are often treated as an emergency.  If patients complain of onset of urinary frequency or problems having a bowel movement in conjunction with sciatica, rapid referral to a surgeon skilled in spinal disorders is necessary.

If radiographic studies performed on any of the occasions mentioned earlier suggest the evidence of a mass lesion, bone infection, significant disc location or slippage, early referral may be appropriate as well.

Similarly, cervical spine lesions are urgent in the presence of evidence of myelopathy, bowel and bladder abnormalities or rapidly progressive weakness. 

Again, the physicians of SpineCare are available to assist you in decision making and determining the appropriateness of referral as well as facilitating timely access to skilled spinal surgeons.
 


Rehabilitation

The purpose of physical therapy in the treatment of spinal disorders is to provide and educate/instruct the patient in methods on how to control pain, how to maintain a healthy back and how to move safely in the environment.  Correction of soft tissue inflexibility from spasm or tightness, improvement in segmental motion, appropriate proprioception and increase in trunk stabilizer strength are goals of treatment.  Acutely, there have been no studies to substantiate use of modalities for symptom control.  However, the patient may benefit from a self administered program of cold application PRN. 

In the first week or two after the injury, appropriate rehabilitation may include home use of ice and stabilizing exercises at least daily.  After 3 or 4 weeks, more comprehensive rehabilitation may be indicated. 

Persistent Back/Neck Pain: Referral to other rehabilitation specialists may be indicated in more complicated spine injuries.  For example, physical therapy should be a component of a comprehensive multidisciplinary approach to helping patients deal with pain.  Psychology services are helpful for stress management and biofeedback.  Occupational therapy can augment physical therapy in addressing advanced ADL issues or permanent modification.  A comprehensive program involving the above specialists in addition to PM & R and vocational counseling is often necessary.


Speaker Bureau

The professionals of SpineCare are available for presentations, individually or together, to a wide variety of groups including professional associations, industry groups, etc.  Please contact SpineCare at 414-955-7199 for further information.  Topics include but are not limited to:

  • Non-surgical treatment

  • Diseases causing back pain

  • Chiropractic treatment

  • Spine injuries and the impact on worker's compensation

  • Back pain and disability

  • Successful return to work

  • Ergonomics

  • Aerobic conditioning and lifestyle changes as related to back injury

  • Case management of clients with back injuries

  • Benefits of rehabilitation services

  • Physical therapy and spine stabilization

 


Suggested Bibliography

  • Bagnall D, Gray G: Functional rehabilitation for low back pain: functional restoration and the lower extremity functional profile. SpineLine 2001;2:5-10.
     
  • Bigos S, Boweyer O, Braen G et al: Acute low-back problems in adults. Clinical Practice Guidelines #14. AHCPR publication 95-064z. Rockville, MD: Public Health Service, US DHHS, Dec 1994.

     
  • Boden SD, Weisel SM: Errors in decision-making following radiographic investigations of the spine. Seminars in Spine Surgery 1993; 5: 90-100.

     
  • Braddom RL: Conservative approach to uncomplicated back pain. Physical Medicine and Rehabilitation State of the Art Reviews 1995; 9(7).

     
  • Brumagne S, Cordo P, Lysens R, Verschueren S, Swinnen S: The role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Spine 2000;25:989-994.

     
  • Butts NK, Tucker M, Greening C: Physiologic responses to maximal treadmill and deep water running in men and women. American journal of Sports Med 1991;19:612-614.

     
  • Cherkin DC, Deyo RA, Battie M, et al: A comparison of physical therapy, chiropractic manipulation, and provision of and educational booklet for the treatment of patients with low back pain. NEJM 1998;339:1021-1029.

     
  • Deyo RA: Conservative therapy for low back pain. JAMA 1983;250:1057-1062.

     
  • Deyo RA: Drug therapy for back pain: Which drugs help which patients. Spine 1996;21:2840-2950.

     
  • Gray G. Lower Extremity Functional Profile. Adrian, MI: Wynn Marketing, Inc; 1995.

     
  • Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine 2001;26:e243-e248.

     
  • Kaser L, Mannion AF, Rhyner A, Weber E, Dvorak J, Muntener M: Active therapy for chronic low back pain, part 2. Effects on paraspinal muscle cross-sectional area, fiber type size, and distribution. Spine 2001;26:909-919.

     
  • Leinonen V, Kankaanpaa M, Airaksinen O, Hanninen O. Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabilitation. Arch Phys Med Rehabil 2000;81:32-37.

     
  • Mannion AF, Muntener M, Taimela S, Dvorak J: A randomized clinical trail of three active therapies for chronic low back pain. Spine 1999; 24:2435-2448.

     
  • Mannion AF, Taimela S, Muntener M, Dvorak J: Active therapy for chronic low back pain, part 1. Effects on back muscle activation, fatigability, and strength. Spine 2001;26:897-908.

     
  • Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J: Active therapy for chronic low back pain, part 3. Factors influencing self-related disability and its change following therapy. Spine 2001;26:920-929.

     
  • Mayer T, Mooney V: Contemporary conservative care for painful spinal disorders. Lea and Febinger Publishers, 1991.

     
  • Mayer TG, Robinson R, Pegues P, Kohles S, Gatchel RJ. Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful? Arch Phys Med Rehabil 2000;81:1143-1150.

     
  • Mazanec DJ: Differential diagnosis of low back pain and sciatica. Seminars in Spine Surgery 1994; 6(3):25-64.

     
  • Mooney V. Treating low back pain with exercise. Musculoskel Med 1995;12:24-34.

     
  • Nelson BW, Carpenter DM, Dreisinger TE, Mitchell M, Kelly CE, Wegner JA. Can spinal surgery be prevented by aggressive strengthening exercises? A prospective study of the cervical and lumbar patients. Arch Phys Med Rehabil 1999;80:20-25.

     
  • Nordin M. 2000 International Society for the Study of the Lumbar Spine Presidential Address: Back to work – some reflections. Spine 2001;26;851-856.

     
  • Rosen NB, Hoffberg HJ: Conservative management of low back pain. Physical Medicine and Rehabilitation Clinics of North America 1998;9(2):435-472.

     
  • Van der Velde G, Mierau D. The effect of exercise on percentile rank aerobic capacity, pain, and self-related disability in patients with chronic low back pain: a retrospective chart review. Arch Phys Med Rehabil 2000;81:1457-1463.

     
  • Wernecke M, Hart D. Centralization phenomenon as a prognostic factor for chronic low back pain and disability. Spine 2001;26:758-765.


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