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Chapter 177. Neck and Thoracolumbar Pain

Amy M. Stubbs

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).

Table 177-1 Symptoms and History Associated with Neck Pain
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Table 177-1 Symptoms and History Associated with Neck Pain

Group 1: Cervical Problems Arising Mainly from Neck Joints and Associated Ligaments and Muscles

Group 2: Cervical Problems Involving the Cervical Nerve Roots or the Spinal Cord

Patients complain of pain and stiffness.

Pain is a deep, dull aching sensation and often episodic.

Patients have a history of excessive or unaccustomed activity or of sustaining an awkward posture.

There is no history of specific injury.

Ligament and muscle pain are localized and asymmetric.

Pain from upper cervical segments is referred toward the head; pain from lower segments, to the upper limb girdle.

Symptoms are aggravated by neck movement and relieved by rest.

Patients complain of significant root pain, typically sharp, intense, and may be described as “burning.”

Pain may radiate to the trapezial and periscapular areas or down the arm.

Patients complain of numbness and motor weakness in a myotomal distribution.

Headache may occur if the upper cervical roots are involved.

Symptoms often become more severe with neck hyperextension (especially when the head is toward the affected extremity).

Patients may experience gradual onset of shocklike sensations spreading down spine to extremities.

Most common myelopathy at the level of the fifth cervical vertebra and affects shoulder abduction (deltoid) and external rotation (infraspinous).

Table 177-2 Symptoms and Signs of Cervical Radiculopathies
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Table 177-2 Symptoms and Signs of Cervical Radiculopathies

Disk Space/ Nerve Root

Pain Complaint

Sensory Change

Motor Weakness/Altered Reflex

C1-2/C1-2

Neck, scalp

Scalp

None/None

C4-5/C5

Neck, shoulder, upper arm

Shoulder, thumb

Infraspinatus, deltoid, biceps/Biceps reflex

C5-6/C6

Neck, shoulder, upper scapula, proximal forearm, thumb

Thumb, index finger, lateral forearm

Deltoid, biceps, pronator teres, wrist extensors/Biceps and brachioradialis reflex

C6-7/C7

Neck, posterior arm, dorsal and proximal forearm, chest, medial scapula, middle finger

Middle finger, forearm

Triceps, pronator teres/Triceps reflex

C7-T1/C8

Neck, posterior arm, proximal forearm, medial scapula, medial hand, ring and little fingers

Ring, little fingers

Triceps, flexor carpi ulnaris, hand intrinsic muscles/Triceps

Table 177-3 Symptoms and Signs of Lumbar Radiculopathies
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Table 177-3 Symptoms and Signs of Lumbar Radiculopathies

Disk Space

Nerve Root

Pain ...

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