Chapter 7: Approach to Neck and Back Pain

Introduction

Neck and back pain are common presenting complaints in emergency department patients. Approximately 70% to 90% of individuals will experience an episode of back pain at some point in their lifetime.^1–3 In a survey, 26% of individuals reported low back pain and 14% reported neck pain within the previous 3 months.⁴ In addition to being common, back pain is costly: spine-related expenditures have been increasing in recent years, costing $86 billion in the United States in 2005.^5,6 In addition, indirect costs related to days lost from work are substantial, with approximately 2% of the US work force compensated for back injuries each year.⁷

The literature reports that an estimated 85% of patients have pain secondary to muscle or ligamentous injury and only a minority of patients have pain because of nerve roots (e.g., herniated disk), facet joints (e.g., arthritis), or the bone (e.g., osteomyelitis).¹ It is the author’s opinion that this imbalance is greatly exaggerated because the majority of muscle spasm and strain is secondary to another injury or disorder that is the primary cause of the pain. This chapter attempts to provide the reader with the tools to better ascertain the difference between these entities. Chapter 8 goes into further details regarding each of these diagnoses, whereas Chapters 9 and 10 focus on the traumatic injuries of the cervical and thoracolumbar spine, respectively.

Whether the exact cause of the patient’s pain can be determined or not, the ability to differentiate life-threatening from benign causes is of paramount importance to the emergency physician. When evaluating a patient with back pain, clinicians should ask themselves two important questions:

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

2. Is neurologic compromise present that would indicate spinal cord injury and necessitate further imaging and surgical consultation?

Anatomy

The spinal column includes 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. The atlas is a ring-like structure that articulates with the skull, where it is responsible for 50% of the neck’s ability to flex and extend. The odontoid process of the axis is secured to the anterior portion of the atlas and allows rotation.

The vertebral bodies gradually increase in size as they descend. The posterior arch encases the spinal cord and consists of the broad pedicles, flat laminae, and the spinous processes (Fig. 7–2). The transverse processes extend laterally near the junction of the pedicles and laminae. The posterior arch has four facets that articulate ...