Chapter 177. Neck and Thoracolumbar Pain

Neck and back pain are common complaints seen in the ED and have a wide array of causes, ranging from benign to life threatening. Workup of these complaints requires a thorough history with careful attention to risk factors for serious pathology. A complete physical examination includes evaluation of specific nerve roots and dermatomes.

Neck and back pain are often due to nonspecific musculoskeletal causes, but symptoms may also be attributable to spinal nerve roots (radiculopathy) or the spinal cord itself (myelopathy) (Tables 177-1, 177-2, 177-3). Thoracolumbar pain may be categorized by symptom duration: acute (<6 weeks), subacute (6 to 12 weeks), or chronic (>12 weeks).

The history should include the pain's circumstances of onset, location (including any radiation), duration, and any exacerbating/alleviating factors. Neurologic complaints should also be sought. Concern for problems such as spinal cord compression should be high when complaints include weakness, paresthesia, or urinary or fecal problems (retention or incontinence). Risk for serious neurologic or bony pathology is higher when there are comorbidities (eg, cancer, rheumatologic disease, osteoporosis), constitutional symptoms such as fever or weight loss, or pain that is unremitting or occurs during the night.

Evaluation of mobility should include attention to presence of severe pain or gait disturbances. The structures of the head, neck, and back should be exposed and palpated for point tenderness, deformity, or signs of infection. A thorough neurologic examination, including assessment of specific nerve roots' strength, sensation, and reflexes, is vital (Tables 177-2, 177-3). Exam maneuvers should be performed as indicated, and may include straight-leg testing or assessment for the Lhermitte sign (electric shock-like pain in the spine and extremities occurring with neck flexion, suggesting cord compression). A rectal examination to evaluate for tone, sensation, masses, or infection should be performed when there are neurologic deficits or concerns for serious disease.

The differentials for neck and back pain are broad but can generally be guided by the history and physical examination. The majority of patients with neck and back pain will not require emergent imaging or diagnostic testing.

Imaging decision-making in patients with neck and back pain is informed by clinical suspicion as well as considerations of cost and radiation exposure. Plain films of the spine have low sensitivity but may be considered as an initial imaging step if clinical suspicions include tumor, fracture, or infection. For patients with pain and neurologic deficits, MRI is the definitive test. CT scan is helpful for identification of disorders of the bony skeleton (eg, fracture, osteomyelitis), but its sensitivity for nerve root or spinal cord disorders is poor. CT myelography can serve as an alternative to MRI, if the latter is contraindicated.

Three views of the cervical spine may be helpful in patients with chronic neck pain or those with a history or trauma, surgery, malignancy, or rheumatologic disease. Flexion-extension films may be considered if instability if suspected. If radiographs are normal, or show only spondylosis (ie, degenerative disease), and if the patient has a benign examination, no further imaging is required. For patients with back pain, if plain thoracic and/or lumbar radiographs are indicated (as discussed above), anteroposterior and lateral views suffice. Compression fractures may be seen on thoracic spine films (eg, in osteoporotic patients). Advanced imaging is necessitated by presence of neurological deficits or abnormal plain radiographs.

Laboratory testing will not be useful in the majority of patients with neck and back pain. If serious pathology (eg, malignancy, infection) is suspected, a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and urinalysis should be ordered. ESR has a sensitivity of 90% to 98% for infectious causes of back pain. Urinalysis is useful to rule out urinary or renal pathology as a pain source. Postvoid residual (PVR) assessment, with ultrasound or catheterization, should be performed on patients complaining of urinary retention. Elevated PVR is the most common finding in cauda equina syndrome, and PVR volume exceeding 100 mL may indicate overflow incontinence due to epidural compression.

Mechanical neck disorders, such as strain caused by trauma, are often characterized by delayed pain and paracervical pain and stiffness. National Emergency X-Radiography Utilization Study (NEXUS) criteria can be utilized to determine the need for imaging (see Chapter 161 “Spine and Spinal Cord Injuries”).

Cervical disc herniation, spondylosis, or stenosis can lead to radiculopathy or myelopathy. Signs and symptoms of a radiculopathy include pain and weakness in a dermatomal distribution (Table 177-2). Lower extremity hyperreflexia, a positive Babinski, or loss of sphincter tone are suspicious for myelopathy; any of these findings necessitate MRI. Metastatic cancer may also cause a radiculopathy or myelopathy and should be included in the differential for chronic pain. Osteomyelitis, epidural abscess or hematoma (consider in patients with coagulopathy), and transverse myelitits may also cause neck pain with neurologic deficits; these disorders are more commonly observed in the thoracic or lumbar spine.

Neck pain can be caused by a variety of other disorders such as myofascial pain syndrome, temporal arteritis, ischemic heart disease, and neurodegenerative disorders. The distribution of symptoms in these disorders will typically not be dermatomal, and they will usually be distinguished by other historical features.

The majority of patients with back pain have nonspecific back pain; they have no radiculopathy or myelopathy and no specific etiology is found. These patients typically have benign examinations and their pain is often exacerbated by movement. Diagnostic evaluation is negative.

As with neck pain, disc herniation and degenerative changes of the thoracic or lumbar spine can be a cause of acute or chronic back pain. More than 95% of disc herniations will be at the L4-L5 or L5-S1 nerve roots, compression of which can cause sciatica. These patients may have leg pain, neurologic deficits localized to a unilateral nerve root, and a positive straight-leg test. Spinal nerve root compression can occur at any level in the thoracic or lumbar spine, with associated localizing symptoms (Table 177-3). Also occurring at any level are epidural compression syndromes which include spinal cord compression, cauda equina syndrome, and conus medullaris syndrome. All epidural compression syndromes may cause pain, neurologic deficits, or autonomic dysfunction at different cord levels. The thoracic spine is the site of most (70%) cases of metastatic epidural compression.

Infectious causes of back pain include osteomyelitis, discitis, and epidural abscess, all of which are often missed on initial presentation. A high level of suspicion should be maintained in patients with risk factors such as immunocompromise, recent back surgery, retained hardware, or intravenous drug use. Plain films may show bony destruction in patients with osteomyelitis, but x-rays are often initially normal in cases of infectious back pain. MRI is typically required for diagnosis. The ESR is will be elevated in the majority of cases.

Other causes of back pain may originate from the spine itself, or from nonspinal causes. Spinal stenosis can cause low back and leg pain that mimics claudication, worsening with walking and improving with rest. CT, MRI, and sometimes angiography are needed to make the diagnosis. Ankylosing spondylitis, an autoimmune arthritis, causes chronic back pain and is identifiable by a characteristic squaring of vertebral bodies on radiography. Transverse myelitis, an inflammatory disorder of the spinal cord, may mimic a compression syndrome. Ruptured abdominal aneurysm, pyelonephritis, pancreatitis, or renal infarction should also be considered in patients with nonspecific back pain accompanied by concerning history or exam findings.

1. Patients with neck and back pain that have progressive neurologic deficits, myelopathy, or intractable pain should be imaged as indicated (typically MRI) and admitted to the appropriate service for further management. Dexamethasone 10 milligrams IV should be given prior to imaging for suspected epidural compression.

2. Patients with a stable or mild radiculopathy may be managed conservatively with pain medication, routine activity, and strict return precautions for worsening symptoms. Outpatient MRI and neurosurgical follow-up should be considered for patients who have failed conservative treatment.

3. Pain management may include NSAIDs (if no contraindication), acetaminophen, or muscle relaxants (eg, diazepam 5 to 10 milligrams PO tid), used singly or in combination; all have been shown to be effective with no agent proved superior. A short course of oral opioids may be prescribed for patients with moderate to severe pain, but long-term use is discouraged. Other treatments such as manipulation or corticosteroids have limited benefit and should not be prescribed in the ED.

4. The majority of patients with neck or back pain will have benign courses and improve with time. These patients may be prescribed pain medicine as appropriate and reassurance should be provided.