Neck and Back Pain
Overview
Neck and back pain, especially pain in the lower back, is one of the most common health problems in adults. Fortunately, most back and neck pain is temporary, resulting from short-term stress on the muscles or ligaments that support the spine rather than from a serious injury or medical condition such as nerve damage or kidney disease.
Anatomy
The back is an intricate structure of bones, ligaments, muscles, nerves, and tendons. The backbone, or spine, is made up of 33 bony segments called vertebrae:
- 7 cervical (neck) vertebrae
- 12 thoracic (middle back) vertebrae
- 5 lumbar (lower back) vertebrae
- 5 sacral (lowest area of the back) vertebrae
- 4 coccygeal (coccyx, or tailbone) vertebra (made up of several fused segments)
The vertebrae are arranged in a long vertical column and held together by ligaments, which are attached to muscles by tendons. Between each vertebra lies a gel-like cushion called an intervertebral disc, consisting of semifluid matter (nucleus pulposus) that is surrounded by a capsule of elastic fibers (annulus fibrosus).
The spinal cord is an extension of the brain that runs through a long, hollow canal in the column of vertebrae. The meninges, cerebrospinal fluid, fat, and a network of veins and arteries surround, nourish, and protect the spinal cord.
Thirty-one pairs of nerve roots emerge from the spinal cord through spaces in each vertebra. The spinal cord and peripheral nerves perform essential sensory and motor activities of the body. The peripheral nervous system conveys sensory information from the body to the brain and conveys motor signals from the brain to the body.
Incidence and Prevalence
In the United States, back pain is reported to occur at least once in 85% of adults below the age of 50. Nearly all of them will have at least one recurrence. It is the second most common illness-related reason given for a missed workday and the most common cause of disability. Work-related back injury is the number one occupational hazard.
Risk Factors
Aging produces wear and tear on the spine that may result in conditions (e.g., disc degeneration, spinal stenosis) that produce neck and back pain. Having a previous back injury puts one at risk for another injury.
Physically demanding occupations that require repetitive bending and lifting have a high incidence of back injury (e.g., construction worker, caregiver). Jobs that require long hours of standing without a break (e.g., hairdresser) or sitting in a chair (e.g., keyboard operator) that does not support the back well put a person at risk for neck and lower back injury.
Being sedentary (i.e., not exercising regularly or engaging in physical recreation) and being overweight, which increases stress on the lower back, are risk factors.
Poor posture, such as slouching in a chair, driving hunched over, standing incorrectly, and using poor body mechanics when lifting and carrying heavy loads are risk factors. Sleeping on a soft or sagging mattress also can lead to back pain.
Sports that involve twisting the back, like golf, can result in back injury or worsen existing lower back pain.
Joint and/or bone disease (e.g., osteoporosis, arthritis) and infectious disease (e.g., spinal meningitis) can lead to degeneration, inflammation, and compression.
Causes
Many conditions can cause back and neck pain, ranging from injury to infection to simply twisting the wrong way. An injury sustained in an automobile or other type of accident can damage muscles, joints, ligaments, and vertebrae.
Overuse or underuse of the back is by far the most common cause of back pain that manifests as tightening or spasm of the muscles that connect to the spine. Inflammation and swelling often occur in the joints and ligaments, especially in the cervical and lumbar regions, as people age.
A herniated disc occurs when the inner material of the disc (nuclear pulposus), pushes through a tear in the capsule of elastic fibers that surrounds the disc (annulus fibrosus), causing nerve root compression.
The cervical and lumbar regions of the spine have the most mobility and the discs there are more likely to wear down or be injured. Ninety percent of disc herniations occur in the lower two lumbar vertebrae.
Over time, repeated daily stress coupled with minor injury can contribute to intervertebral disc degeneration. The annulus fibrosus, the capsule of elastic fibers that surrounds the disc, may develop small tears and form scar tissue.
As more scar tissue forms, the nucleus pulposus, the semifluid inner portion of the disc, begins to dry up. Over time, the disc collapses and significantly narrows the space between vertebrae, causing spinal stenosis.
Spinal stenosis, narrowing of the spine, can cause spinal cord irritation and injury. Conditions that cause spinal stenosis include infection, tumors, trauma, herniated disc, arthritis, thickening of ligaments, growth of bone spurs, and disc degeneration. Spinal stenosis most commonly occurs in older individuals as a result of vertebral degeneration.
A pinched nerve, or radiculopathy, occurs when something rubs or presses against a nerve, creating irritation or inflammation. Radiculopathy can result from a herniated disc, bone spur, tumor growing into the nerves, and vertebral fracture, and many other conditions.
Sciatica is a certain type of radiculopathy that involves inflammation of the sciatic nerve. Pain is experienced along the large sciatic nerve, from the lower back down through the buttocks and along the back of the leg.
A spinal tumor that originates in the spine (primary tumor) or spreads to the spine from another part of the body (metastatic tumor) can compress the spine or nerve roots and cause significant pain.
An infection that develops in the vertebrae (e.g., vertebral osteomyelitis), the discs, the meninges (e.g., spinal meningitis), or the cerebrospinal fluid can compress the spinal cord and result in serious neurological deterioration, if it is not diagnosed and treated immediately.
Facet joints allow movement of the spine. These consist of two knobs, or facets, that meet between each vertebra to form a joint. As facet joints degenerate, they may not align correctly, and the cartilage and fluid that lubricates the joints may deteriorate. Bone then rubs against bone, which can be very painful.
Bone and joint diseases (e.g., osteoporosis, ankylosing spondylitis, osteoarthritis) can cause degeneration, inflammation, and spinal nerve compression.
Pain can radiate to the back from other areas of the body (i.e., referred pain) affected by disease or injury, such as bleeding from the aorta, the large artery that carries blood out of the heart; pancreatic disease; pneumonia; kidney diseases; bladder disorders; and uterine abnormalities.
Signs and Symptoms
Pain can be constant or intermittent. Intensity can vary from a dull ache to searing agony. The onset may be sudden, with or without apparent reason, or gradual.
Most back pain resolves in a few days or weeks with or without treatment. However, some people have chronic pain that lasts months or years.
Severe pain lasting more than a few days without improvement may require medical attention. Anyone having difficulty passing urine; numbness in the back or genital area; numbness, pins and needles, or weakness in the legs; shooting pain down the leg; or unsteadiness when standing should see a physician immediately.
Localized pain is often described as aching, tight, stiff, sore, burning, throbbing, or pulling. The pain may worsen while bending, sitting, walking, or standing too long in one position. It may also be more prevalent at different times of the day, such as when a person wakes up in the morning.
Pinched nerves produce numbness or tingling, warm or cold sensations, and burning or stabbing pain that begins in the back and radiates down the leg (e.g., sciatica) or arm. Activities such as coughing, sneezing, or walking may increase pressure on the pinched nerve and aggravate the pain.
Compressed nerves cause numbness and weakness in the muscle associated with the nerve. The muscle may atrophy if the compression is not relieved. An infection affecting the spinal cord or nerves may produce fever and lethargy as well as symptoms of compression.
Diagnosis
Diagnosing the underlying cause of neck and back pain can be difficult. A medical history is taken and a complete physical examination, which may include a neurological examination, is performed.
Laboratory Tests
X-rays show the alignment of the cervical, thoracic, and lumbar spine; and may reveal degenerative joint disease, fracture, or tumor.
Magnetic resonance imaging (MRI scan) provides clear images of disc deterioration, pathologies of the spinal cord, spinal stenosis, herniated discs, spinal tumors, and abnormalities in nerves and ligaments. Contrast dye may be injected to highlight problematic areas.
Computerized tomography (CT scan) is an x-ray that utilizes computer technology and can be enhanced with contrast dye. It is used to show abnormalities in bones and soft tissue. CT scan can be used for patients who are unable to tolerate MRI.
Myelography is used to examine the spinal canal and cord. Contrast dye is injected into the cerebrospinal fluid to outline the spinal cord and nerve roots, thus allowing abnormal disc conditions or bone spurs to be visualized with x-ray or CT scan.
Electromyogram (EMG) uses tiny electrodes inserted into muscle tissue to test for abnormal electrical signals, which may indicate that a nerve root is pinched or irritated at the spine.
Spinal tap involves drawing a sample of cerebrospinal fluid and analyzing it for elevated pressure, infection, bleeding, or tumor.
Bone scan locates problems (e.g., fracture, osteoporosis) in the vertebrae. A radioactive tracer is injected into the patient and after several hours, x-ray will reveal bone undergoing rapid changes where large amounts of tracer accumulate.
Treatment
Most cases of back and neck pain are treated conservatively. If pain persists or worsens, or if other symptoms develop, a more aggressive approach is taken.
Home Remedies
Applying ice immediately during the 48 hours after straining a muscle can reduce pain. Ice slows inflammation and swelling, numbs soft tissue, and slows nerve impulses in the injured area. After spasms and acute pain subside, heat can be applied to loosen tight muscles.
Two or three days of bed rest followed by a gradual return to normal activity is sometimes recommended.
Medication
Acetaminophen and ibuprofen are most commonly recommended for pain relief. Package directions or the advice of a physician should be followed.
To relieve acute back pain, anti-inflammatory drugs (e.g., Celebrex®), non-narcotic pain relievers (e.g., Tramadol®), muscle relaxants (e.g., Flexeril®), and narcotic pain relievers may be prescribed.
An oral steroid (e.g., prednisone) is sometimes prescribed for acute episodes of low back pain. Patients are started on a high dose that is gradually reduced over 5 or 6 days. Serious side effects associated with steroid use include bone loss, impaired wound healing, and headache.
Chronic back pain caused by nerve root damage is sometimes treated with tricyclic antidepressants, such as amitriptyline (Elavil®) and nortriptyline (Pamelor®), for numbness, burning, aching, throbbing, or stabbing pains that shoot down the limbs. Side effects include drowsiness, dry mouth, and constipation.
Anticonvulsant drugs, such as gabapentin (Neurontin®), may alleviate pain caused by nerve degeneration and persistent leg pain after surgery. The pain relieving action of anticonvulsants is not well understood. Side effects include drowsiness, dizziness, fatigue, and impaired motor coordination.
Injections
Steroid injections can significantly decrease inflammation and pain caused by spinal stenosis, disc herniation, and degenerative disc disease. A steroid is injected directly into the membrane that surrounds the nerve roots (dura). Selective nerve root block (SNRB) uses a steroid with anesthetic.
Physical Therapy
The goals of physical therapy are to decrease pain, increase function, restore normal movement, and prevent recurrences.
Massage therapy increases circulation to the affected area. There are several techniques and devices used in massage therapy.
Electrotherapy involves sending gentle electric currents through the skin to stimulate muscular contraction, increase muscle strength, and increase the flow of neurochemicals to the area.
In ultrasound, sound waves penetrate the skin and cause soft tissues to vibrate, creating deep gentle heat that increases blood flow, relieves pain and inflammation, and reduces muscle spasms.
Exercise
Exercise can correct current back problems, help prevent new ones, and relieve back pain, particularly after an injury. Proper exercise strengthens back muscles that support the spine and strengthens the abdomen, arms, and legs, reducing strain on the back. Exercise also strengthens bones and reduces the risk of falls and injuries.
It is essential to speak with a doctor or physical therapist before starting an exercise regimen to ensure that it is appropriate.
Adjustment
Chiropractors and osteopaths manipulate the spine, called an adjustment, to relieve pain arising from musculoskeletal conditions such as facet joint injuries, osteoarthritis, and whiplash.
Acupuncture
An acupuncturist inserts hair-thin needles under the skin, which remain in place for 15 to 30 minutes. The needles cause little or no pain. Pain relief may result from the release of endorphins, the body's intrinsic painkillers. Generally, several sessions are needed.
Surgery
Surgery may be indicated for progressive or severe neurological dysfunction-such as muscle weakness, spinal cord compression, or bowel, bladder, or sexual dysfunction-and for cases of pain that is not easily relieved.
Discectomy is the removal of herniated disc material that is compressing nerves. Laminectomy, or removal of the lamina, relieves compression on the spinal cord. Spinal instability is corrected by using a bone graft to fuse adjacent vertebrae.
Implanted pumps deliver a constant rate of pain-relieving medication to the spinal area. Surgically implanted spinal cord stimulators modulate the pain response, so the patient experiences less pain.
Prevention
There is much that a person can do to maintain a healthy back. Preventative measures are especially important if back pain has already been experienced:
- Learn proper body mechanics, particularly if an occupation involves repetitive bending, lifting, and twisting.
- Exercise regularly to keep back muscles strong and flexible.
- Maintain good posture.
- Avoid standing or sitting in one place for long periods of time.
- Maintain weight within an ideal range for body size.
- Eat a healthy diet.