Neck and Low Back Pain

Definition:
Spinal pain indicates the development of a pain generator, potentially due to a wide variety of causes, resulting in pain somewhere in the spine including the neck, upper back, and lower back.

Symptoms:
Patients typically complain of pain emanating from the neck, upper back, and/or lower back, or some combination of these areas. The pain symptoms can also include radiating pain into the shoulder girdle regions, buttock and hip areas, as well as into the upper and/or lower extremities. Radiating pain in the upper extremities can occur on the basis of “referred pain,” or can be due a combined clinical picture of spinal pain with a source of nerve entrapment of exiting nerve roots or the spinal cord itself.

Patients typically present with spinal pain in the neck, upper back, lower back, or a combination of these areas. Often the pain can radiate into the shoulder girdle, buttock, or hip regions, as well as is into upper or lower extremities. Radiating pain from the spine can occur on the basis of “referred pain,” and back pain syndromes often are associated with nerve entrapment syndromes, which can result in radiating upper and lower extremity pain with neurologic symptoms on the basis of both spinal pain and a syndrome of nerve entrapment. Spinal pain due to inflammation of joint structures, whether disks or facets, usually is aggravated with activity that increases the stress in the spine or posturally induced. On the other hand, spinal pain due to fractures, infections, and tumors tends to be constant and unrelenting, present at all times, and not particularly aggravated with certain activities or postures.

Treatment:
The first priority in evaluating a patient with spinal pain is to determine as accurately as possible the patient’s true pain generator. Given that the list of diagnostic possibilities is quite extensive, at a minimum, x-rays should be obtained, and frequently additional diagnostic imaging, usually in the form of an MRI, is appropriate. The most common pain generators in the spine are the joints that support body weight and allow for movement within the spine itself. Disk related spinal pain is probably the most common source, followed by pain in the facet joints or a combination of both. A small minority of patients can have pain attributable to the sacroiliac joint regions. Additional diagnostic possibilities include spinal fractures, including compression fractures in the older age groups, and infections and tumors.

The type of treatment obviously depends of the underlying diagnosis or cause of the patient’s spinal pain. Joint related pain in the spine typically is responsive to a period of restricted activity with symptomatic measures, adjunctive use of prescription medications, specifically tailored physical therapy interventions, and often spinal injections are helpful both diagnostically and therapeutically. Occasionally, if a patient has a severe unrelenting pain unresponsive to nonoperative measures, then surgical intervention can be considered. Surgical procedures for relief of spinal pain alone not combined with nerve entrapment syndromes, however, tends to result less gratifying outcomes than operations performed for relief of nerve entrapment that involves radiating upper or lower extremity pain and neurologic symptoms. Chronic pain patients, including patients with failed back syndromes, often are best treated in the context of a comprehensive pain management program, and are occasionally candidates for implantation of devices such as a spinal infusion pump or spinal cord stimulator.

If Left Untreated:
A first time episode of spinal pain actually carries a quite favorable outlook in that the vast majority of patients will improve over time even if left untreated. The duration of the pain episode, however, can be significantly impacted through prompt institution of appropriate nonoperative treatment measures as noted above. Patients with recurrent pain episodes, particularly if increasing in frequency and severity, typically have a progressive course of worsening over time. The failure of the patient to pursue appropriate activity modification and institute an appropriate program of spinal rehabilitation may cause progressive injuries to their spines if left untreated. Obviously, if the underlying pain is the result of fracture, infection, or tumor, the consequences of failure to pursue diagnosis and treatment can be life impacting and potentially life threatening.

Rehabilitation:
Typically, nonoperative measures are initially pursued unless there are compelling neurologic deficits that demand consideration of early surgical intervention in order to avoid irreversible neurologic deficits. Non-operative measures usually include restriction of activity, use of adjunctive prescription medications, physical therapy measures directed towards relief of nerve entrapment, some form of low impact cardiovascular conditioning, and often spinal injections. Should the patient fail to improve with nonoperative measures, surgical intervention can be discussed, tailored specifically towards removal of the offending lesion causing nerve entrapment. The level of surgery falls along quite a wide spectrum, ranging from the simplest type of intervention in the form removal of a single disc herniation to surgery for relief of nerve entrapment occurring at multiple levels, also requiring spinal stabilization and/or correction of spinal deformity in order to provide a comprehensive solution to the patient’s problems.

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