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Chapter 177: Neck and Back Pain

Amy M. Stubbs

INTRODUCTION

Neck and back pain are major causes of disability in the United States and are commonly seen in the ED. While the majority of cases have nonspecific or benign etiologies, serious underlying pathology may exist. Clinicians must be vigilant in obtaining a thorough history, focusing on risk factors for pathology, and physical examination that includes a detailed neurologic examination.

CLINICAL FEATURES

Neck and back pain have myriad causes, but can often be classified into two groups: uncomplicated musculoskeletal pain and those with pain attributable to radiculopathy (spinal nerve root compression) or myelopathy (spinal cord compression) (see Tables 177-1, 177-2, and 177-3). Thoracolumbar pain may also be categorized by symptom duration: acute (<6 weeks), subacute (6 to 12 weeks), or chronic (>12 weeks).

Table 177-1

Differentiating Cervical Radiculopathy from Uncomplicated Musculoskeletal Neck Pain

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Table 177-1

Differentiating Cervical Radiculopathy from Uncomplicated Musculoskeletal Neck Pain
Factors Favoring Cervical Radiculopathy or Myelopathy* Factors Favoring Uncomplicated Musculoskeletal Neck Pain*
Pain from the neck radiates down the arm in dermatome pattern. Tenderness of involved muscles; examiner may find a focal point of tenderness.
Sensory changes along dermatome distribution. Atrophy or thinning of shoulder muscles may occur after rotator cuff injury.
Pushing down on top of head, with neck in extension (chin up) and head leaning toward symptomatic side elicits pain, typically toward or down the arm (positive Spurling's sign); 90% specific, 45% sensitive. Pain increases with shoulder abduction on the side of neck pain (increased pain could derive from rotator cuff-related pain; radicular pain may decrease with this maneuver).
Pain may worsen with Valsalva, which increases intrathecal pressure. Repetitive movement of arm or shoulder at work or play; may be new activity.
Flex neck forward until chin meets chest or pain stops movement. An electric shock sensation radiating down spine into both arms is a positive result (Lhermitte's sign). Occasionally, paresthesias occur. History of recent injury or recent event of awkward position (such as neck or head position during sleep in an unfamiliar setting) or awkward standing posture to accommodate a special situation.
Depressed reflexes or, uncommonly, increased reflexes (see also Table 177-2). Pain is accompanied by “stiffness” of involved muscle group.

*Patient in either pain category is not expected to have all, or majority, of listed signs.

Table 177-2

Signs and Symptoms of Cervical Radiculopathy

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Table 177-2

Signs and Symptoms of Cervical Radiculopathy
Disk Space Cervical Root Pain Complaint Sensory Abnormality Motor Weakness Altered Reflex
C1–C2 C2 Neck, scalp Scalp
C4–C5 C5 Neck, shoulder, upper arm Shoulder Infraspinatus, deltoid, biceps Reduced biceps reflex
C5–C6 C6 Neck, shoulder, upper medial, scapular area, proximal forearm, thumb, index finger Thumb and index finger, lateral forearm Deltoid, biceps, pronator teres, wrist extensors Reduced biceps and brachioradialis reflex
C6–C7 C7 Neck, ...

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