Evaluation and Management of Neck and Back Pain

John W. Martel, MD, PhD, FACEP; Samuel B. Potter, MD

Disclosures

Semin Neurol. 2019;39(1):41-52. 

In This Article

Acute Neck Pain

Previous reports have suggested that up to 16% of U.S. adults report neck pain annually, with one-third also reporting concomitant lower back pain.[49] Common risk factors associated with acute neck pain include history of previous injury,[50] workplace-related physical demands, and female gender.[50,51] Neck pain may arise either from focal anatomy or be referred, and similar to acute back pain, a specific etiology is often not identified even when radiographic studies are obtained.[52] Red flag symptoms concerning for potentially clinically significant underlying disease include (1) acute or prior localized traumatic injury; (2) evidence of systemic illness, vital sign abnormalities, presence of a structural mass/history of neoplasm, immunosuppression, or IVDU; (3) presence of acute neurological deficits; (4) anterior neck pain (generally a nonspinal etiology); and (5) acute neck pain associated with headache (e.g., meningitis, carotid/vertebral dissection), vision change (e.g., temporal arteritis), or concomitant muscle girdle discomfort (e.g., polymyalgia rheumatica).

Common and Concerning Causes of Neck Pain

  • Cervical strain

  • Cervical radiculopathy/cord compression

  • Cervical artery dissection

  • Meningitis

Cervical strain: Acute strain of neck musculature is associated with a wide variety of nontraumatic causes, ranging from sleeping position to posture, and may be complicated by suboptimal workplace ergonomics. There may be associated upper back and shoulder tenderness that can persist for up to 6 weeks, thought to occur secondary to mild cervical paravertebral musculature injury and associated muscle spasm. However, there are no acute neurological deficits associated with this syndrome, and their presence suggests a different and potentially more serious etiology.

Cervical radiculopathy: Discomfort associated with cervical disc herniation is often attributed to nerve root compression leading to radiating upper extremity discomfort that resembles a similar character to sciatica pain in the lower extremity. It has been estimated that up to 22% of patients reporting cervical radicular discomfort have an associated lateral disk herniation.[52]

Cervical artery dissection: Carotid and vertebral artery dissections occur with intimal wall disruption that enables creation of a false lumen and accumulation of blood leading to formation of an intramural hematoma (Figure 6). They are commonly associated with headache, neck pain as well as acute neurological deficits in more severe cases. In particular, patients may present with Horner's syndrome, which comprises a triad of ptosis, miosis, and anhydrosis. This deficit is seen in ~25% of cases, and has been attributed to distension of sympathetic fibers that traverse the external surface of the internal carotid artery.[53] However, it should be noted that anhydrosis is typically not seen as the path of nerve fibers responsible for facial sweating ascends the external carotid artery. In addition, cranial nerve deficits and cervical nerve root impingement may also be seen.[45] Spontaneous cervical artery dissections are known to occur in association with minor trauma (e.g., sports-related) and connective tissue disease (e.g., Marfan syndrome), and are considered to be a leading cause of stroke in younger patients (under age 40).[54]

Figure 6.

Vertebral artery dissection. CTA image of a left vertebral artery dissection with flap resulting in acute neck pain and vertigo. CTA, CT angiography.

Meningitis: Acute neck pain is commonly reported by patients with inflammation of the leptomeninges that surround the brain and spinal cord. Bacterial meningitis is considered one of the 10 most common infectious causes of death worldwide.[55] Neck pain is also associated with the more common and less deadly viral-associated meningitis that primarily affects children and accounts for nearly 40,000 hospitalizations annually.[56,57] Although both entities may present with symptoms that include fever, neck stiffness, altered mental status, and photophobia, nuchal rigidity may be absent even in the presence of a bacterial process.[57] It has been estimated that 44% of nearly 700 cases of community-acquired bacterial meningitis presented with concomitant fever, nuchal rigidity, and altered mental status. Alternatively, upwards of 95% of patients with an ultimate diagnosis of bacterial meningitis reported at least two of the following four symptoms: headache, nuchal rigidity, altered mental status, and fever.[58] Patients with meningitis seldom are normothermic.[59] Although high fever is most common, hypothermia does also occur as well.[60] In contrast to bacterial meningitis, supportive therapy is recommended for most viral-mediated infections in immunocompetent patients. However, treatment is recommended in the setting of herpes simplex virus (HSV) or human immunodeficiency virus (HIV) associated infections.

History

Similar to the evaluation of atraumatic back pain, obtaining a thorough and targeted history is vital to establishing an appropriate threshold of concern for serious neck pathology. In this case, the past medical history may also point to a certain organ system as the root cause of the complaint, such as prior head/neck malignancy or periodontal disease in the case of neck masses, stroke risk factors (e.g., cardiovascular disease or prior stroke/arterial dissection), or focal neurological deficit in the case of cervical arterial dissection. In addition, a history of prior neck trauma, pain, and/or radicular upper extremity symptoms should prompt further physical examination as well as potential imaging.

Physical Exam

A complete neurologic exam is required, and abnormal findings such as Horner's syndrome, extremity sensorimotor deficits, gait disturbance, hyperreflexia, and/or Babinski sign all contribute important information to narrowing the differential diagnosis. Maneuvers specific to individual diagnoses are discussed below.

Cervical radiculopathy: There are several clinical tests utilized to evaluate for cervical radiculopathy. The Manual Distraction Test is performed by exerting a manual vertical upward traction under the patient's mandible and occiput.[61] The test is considered positive if discomfort is decreased with the maneuver associated with relief of pressure exerted on nerve roots. The Spurling Maneuver is performed by turning the patient's head to the affected side and applying downward pressure at the cranial vertex. Reproduction of ipsilateral radicular discomfort is considered to be a positive result. In each case, care must be taken to avoid these maneuvers in patients with suspected trauma, rheumatoid arthritis, metastatic disease, or known cervical bony malformations. Elvey's Upper Limb Tension Test is an upper extremity analogue of the so-called Straight Leg Raise used to evaluate lower extremity radiculopathy. It is performed by turning the patient's head to the contralateral side while simultaneously abducting the ipsilateral shoulder and extending the elbow. Reproduction of radicular discomfort that radiates down the extremity is considered to be positive.

Meningitis: The Brudzinski and Kernig signs are each associated with a specific clinical maneuver utilized in the evaluation of nuchal rigidity; positive findings raise concern for potential meningitis. A positive Brudzinski's signrefers to spontaneous hip flexion in response to passive neck flexion, whereas a positive Kernig's sign refers to the inability to extend the knee during 90-degree hip flexion or if lower back pain is reproduced. Although sensitivity of each test is considered to be low, specificity approaches 95%.[62]

Cervical cord compression: Shock-like paresthesias occurring with neck flexion (Lhermitte's phenomenon) suggests compression of the cervical cord by a midline disc herniation or spondylosis, but may also be a sign of intramedullary pathology such as focal demyelination. Patients with narrowed spinal canals (e.g., cervical spondylotic myelopathy) may experience focal symptoms similar to those associated with compressive lesions (e.g., tumor, epidural abscess), such as upper extremity sensorimotor deficits, as well as bladder incontinence and ataxia.

Emergency Department Work-up

Similar to acute, atraumatic back pain, routine imaging is not indicated for patients who present with symptoms of cervical strain in the context of a normal neurologic exam. Specific imaging modalities are discussed below with specific indications for each.

Neuroimaging

CT and MRI are both routinely used in the evaluation of select neck pain complaints. MRI is specifically indicated when there is concern for spinal cord compression, infection (SEA/osteomyelitis/discitis), and malignancy.[63] In contrast, CT is preferred when there is suspicion for deep space neck infection.[64]

Cervical Strain and Radiculopathy

The utility of imaging is low and a combination of history and physical examination is generally sufficient.

Cervical Arterial Dissection

Patients presenting with severe acute neck pain and/or headache with concomitant focal neurological deficits require advanced imaging to evaluate for arterial dissection. CTAs of both the neck and brain vasculature are first-line investigative studies in the ED due to rapid availability, and offer similar sensitivity and specificity as magnetic resonance angiography (MRA).[65]

Meningitis

Although imaging is not necessary in most meningitis evaluations,[66] there are several specific instances where it should be considered. Per current Infectious Disease Society for America (IDSA) guidelines, a noncontrast CT brain study should be obtained prior to lumbar puncture when there is concern for immunocompromised states (e.g., HIV infection, current immunosuppressive therapy, and history of solid organ/hematopoietic stem cell transplant), history of structural CNS disease (e.g., mass lesion and stroke), new onset seizure, papilledema, altered mental status, or a focal neurological deficit.[67] The priority is to identify patients with a mass lesion or other potential cause of increased intracranial pressure.

Cervical Mass Lesion

CT of the neck soft tissue with contrast is the study of choice when concerned with potential a neck mass or deep space infection, especially in the setting of a prior history of neoplasm or periodontal disease.[68]

Disposition

Patient disposition varies widely from immediate discharge with conservative therapy to emergent subspecialist consultation and operative intervention. Patients with normal vital signs who do not exhibit evidence of acute systemic infection or neurologic/vascular compromise usually can be discharged with close outpatient follow-up. Up to 90% of patients who are discharged with a diagnosis of acute back pain experience resolution of symptoms within 4 to 6 weeks.[3–6]

Those patients with a life- and/or function-threatening diagnosis generally require emergent advanced imaging, specialist consultation, and admission as detailed in previous sections. Neurosurgical evaluation is necessary for those with acute cord compression stemming from a variety of causes, including disc herniation, adjacent hematoma, vertebral osteomyelitis, discitis, and SEA. In addition, radiation oncology evaluation may also be required where primary neoplastic or metastatic lesions are the underlying cause of acute cord compression.[6] For those patients with symptomatic disc herniation that does not cause acute cord compression but is associated with nerve root impingement, advanced imaging followed by urgent surgery may also be performed in select cases (e.g., acute foot drop).

Those patients with emergent vascular pathology such as rAAA or aortic dissection also require immediate surgical evaluation. Infectious etiologies such as vertebral osteomyelitis, discitis, and SEA require broad-spectrum IV antibiotics in conjunction with surgical evaluation. Up to 40% of patients with vertebral osteomyelitis may develop complications requiring surgery.[69]

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