Evaluation and Management of Neck and Back Pain

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


Semin Neurol. 2019;39(1):41-52. 

In This Article


  • Eighty-five to 90% of patients with back pain have no clear etiology, and symptoms resolve in 4 to 6 weeks.

  • Two percent of back pain complaints can be attributed to a life-threatening or permanently disabling process.

  • Disc herniations occur most commonly at the L4, L5, and S1 levels.

  • Careful consideration of the risk and benefit of opioid therapy should be considered on an individual basis when initiating therapy for muscular and radicular low back pain.

  • Cauda equina syndrome is an acute surgical emergency composed of several key symptoms, including urinary retention, urinary overflow and/or fecal incontinence, decreased rectal tone, and saddle anesthesia.

  • Metastatic disease involvement of vertebral bone is most commonly seen in the thoracic spine and is associated with primary breast, lung, prostate, kidney, and thyroid carcinomas.

  • Up to 80% of cancer patients who present with acute back pain may have underlying metastatic disease.

  • Aortic dissection and rAAA can each present with acute back pain, and both have a high mortality when unrecognized and/or when treatment is delayed.

  • Back pain occurs in 20% of rAAA cases; abdominal ultrasound is 100% sensitive and 98% specific.

  • Red flag signs and symptoms should be interpreted within the context of the entire clinical picture as they have a high false-positive rate when used alone.

  • Malingering and underlying psychosocial etiologies of acute back pain are diagnoses of exclusion (Table 3—Waddell's score).

  • MRI is the diagnostic imaging test of choice in the evaluation of cauda equina syndrome as well as primary neoplastic/bony metastatic lesions and vertebral osteomyelitis.

  • X-ray followed by MRI is the diagnostic imaging test of choice in the evaluation of fracture and spondylolisthesis, especially in children.

  • CTA is the diagnostic test of choice in the evaluation of cervical arterial dissection, rAAA, and aortic dissection.