Chapter 7: Approach to Neck and Back Pain

INTRODUCTION

Neck and back pain are among the most common presenting complaints in emergency department (ED) patients. While the quoted lifetime prevalence of back pain varies within medical literature, approximate figures range up to 84%, suggesting the vast majority of individuals will experience an episode of back pain at some point in their lifetime.¹ On a global scale, neck and lower back pain remained the leading cause of disability in the world from 1990 to 2015.² In a US-based survey involving more than 31,000 individuals, low back pain lasting at least a whole day in the past 3 months was reported by 26.4% of respondents, and neck pain was reported by 13.8%.³

Back pain is not only common but also costly, with total costs in the United States exceeding $100 billion per year. Two-thirds of these costs are indirect, attributed to lost wages and reduced workplace productivity.⁴ Lower back pain accounts for one-third of all occupational musculoskeletal injuries and illnesses resulting in work disability.⁵ Although two-thirds of lower back pain cases return to work within 1 month, 17% of patients experience work disability between 1 and 6 months while 7% of cases require more than 6 months to return to work.⁶

Literature reports an estimated 85% of patients have back pain secondary to muscle or ligamentous injury and only a minority of patients have pain originating from nerve roots (e.g., herniated disk), facet joints (e.g., arthritis), or the bone (e.g., osteomyelitis).⁷ However, this imbalance is likely exaggerated as the majority of muscle spasm and strain is the result of a different injury or disease process, which is the primary cause of pain. This chapter aims to provide the reader with tools to ascertain the differences between these entities. Chapter 8 delves into further details regarding each disease while Chapters 9 and 10 focus on traumatic injuries of the cervical and thoracolumbar spines, respectively.

Regardless of whether the exact etiology of the patient's pain can be determined, the ability to differentiate life-threatening from benign causes of back pain is of paramount importance to the emergency physician. When evaluating a patient with back pain, two important questions need to be considered:

• Is there a serious underlying systemic disease responsible for the pain?

• Is there evidence of neurologic compromise that indicates spinal cord injury and necessitates emergent imaging and surgical consultation?

ANATOMY

The spinal column consists of 33 vertebrae: 7 cervical, 12 thoracic, and 5 lumbar (Fig. 7–1). The sacrum consists of five fused vertebrae and the coccyx. The first two cervical vertebrae, the atlas (C1) and axis (C2), are unique from the remainder of the cervical spine. The atlas is a ring-shaped structure that articulates with the skull, and is responsible for 50% of the neck's mobility in flexion and extension. The odontoid process of ...