Statistically, 4 out of every 5 adults under the age of 50 have experienced at least one episode of neck or back pain. For most people, the symptoms resolve in a reasonable period of time with or without intervention. For others, the symptoms become chronic, often leading to surgical procedures and even disability. Sometimes, there is a specific identifiable incident that incited the pain while in other cases, no particular injury or overuse syndrome could be identified. Neck and back pain are one of the most common complaints leading to medical evaluations in the emergency room, urgent care center or primary care physician’s office; they are also a significant cause of lost time from work, lost wages and productivity, and high expenditure from a healthcare perspective.
Neck and back pain are symptoms of an underlying problem. The majority of the causes (~97%) are purely mechanical, that is related to the mechanics of movement of the neck or back, involving the bones, muscles, ligaments, discs and joint spaces. They include such diagnoses as lumbar strain/sprain, degenerative disc disease, herniated discs, spinal stenosis, spondylolisthesis, osteoporotic compression fracture and traumatic fractures. Some of these, obviously, are more serious with potential neurologic sequellae than others. Any condition that results in compression of the spinal cord can cause permanent neurologic injury, including paralysis; these include fractures, stenosis and significant spondylolisthesis. Causes include acute traumatic injuries (car accidents, falls, direct blows), overuse syndromes, poor lifting techniques, poor posture, chronic degenerative arthritis leading to spinal stenosis and spondylolisthesis, and osteoporosis.
The remaining 3% of causes of neck and back pain are considered non-mechanical, but they can be further divided into non-mechanical spinal conditions (1%) and visceral (internal organ-related) conditions (2%). Of the non-mechanical spinal conditions, neoplasias/malignancies comprise 0.7% while infections and inflammatory arthritides (inflammation of joints due to infectious, metabolic, or constitutional causes) comprise the remaining 0.3%. Of the 2% visceral complications, etiologies are potentially due to vascular problems (aortic aneurysms, retroperitoneal hemorrhage, coronary syndromes, etc.), prostatitis, endometriosis, pelvic inflammatory disease, kidney stones/infections, pancreatitis, cholecystitis or ulcer perforation. Thus, the sub-categories of non-mechanical neck and back pain have very small incidences in the global sense, but they are potentially more serious with more ominous consequences, including paralysis and death, making them diagnoses not to be missed or ignored.
So, how can one tell the difference between mechanical versus non-mechanical neck or back pain?
As a general rule, mechanical neck/back pain, since it is related to movement, is typically worse with movement or specific body positions and better with rest or lying supine without the burden of one’s weight causing an axial load on the vertebral column. Non-mechanical neck/back pain is relatively constant and not related to body position or movement. Pain in either case can be sharp or dull/aching, and each can have instances in which there is neurologic involvement causing pain to radiate along the nerves that exit the spinal column. In the neck, nerve pain typically radiates to the arms causing pain, numbness and sometimes weakness. In the upper to mid-back, nerve pain typically radiates to the anterior chest and abdomen. In the lower back, nerve pain typically radiates into the pelvis, genital area, and especially the legs. Radicular pain can be either one-sided or bilateral, the latter of which is more ominous and indicative of spinal cord compression as opposed to a single peripheral nerve root.
What are the “red flags” that raise concern for more serious problems?
There are specific risk factors that, when present, raise concerns for more systemic disease processes. A history of cancer, for instance, increases the likelihood of the pain being related to a metastatic lesion or tumor. Presence of a fever increases the likelihood of the pain being related to an infectious etiology. Unexplained weight loss increases the likelihood of the pain being related to either a primary malignancy or metastatic cancer. A history of intravenous drug use or even diabetes increases the risk for an acute or chronic infectious cause. Blood in the urine can indicate a malignancy or other kidney-related problem. Swollen glands can be indicative of a malignancy or infectious problem. Anemia can be indicative of an underlying malignancy or vascular problem. Rashes are often associated with rheumatologic or auto-immune problems that often involve the joints. Chronic steroid use or other immunosuppression can increase the risk of infectious causes or osteoporosis with compression fracture. Obviously, a history of trauma increases the risk of fracture, disc rupture/herniation and ligamentous injury leading to spinal instability, but it can also be a cause of intra-abdominal injuries or retroperitoneal injuries that present as back pain. Any time there are neurologic deficits (numbness, tingling, weakness, muscle atrophy, etc.) beyond sciatica, the risk of nerve compression or spinal cord compression becomes higher. Abdominal pain associated with back pain can be related to an intra-abdominal process (infection, abscess, aneurysm, ulcer perforation, etc.). Neck pain that is associated with headache, fever and neck rigidity is often indicative of menigitis.
Overall, there are a plethora of potentially serious causes of neck and back pain. One can see that the diagnosis of more serious conditions can be a little more complicated, especially since they are much rarer than the common, everyday, garden-variety mechanical back pain without complications. There are, however, a variety of clues that can lead one to an accurate and relatively rapid diagnosis. The intention of this blog has been to introduce the topic and the dilemma faced by a provider when diagnosing these conditions. Since the topic is broad and more complicated, a series of blogs dedicated to some of the more devastating etiologies of neck and back pain will follow. The key to diagnosing any condition is an accurate and in-depth history and physical examination with keen attention to specific clues that are typically present.