Pain in the neck or back can severely limit one's ability to function in everyday life and often causes great anxiety that a serious threatening condition may have arrived. Fortunately for the vast majority of those afflicted, no surgery will be necessary usually and there is often a good recovery with conservative measures.
The patient and doctor must work together in understanding the mechanism of the pain affecting the patient to effect the best treatment plan. A detailed history of any event associated with onset, where exactly the pain is located, where does it radiate, what makes it worse or better, any preexisting health problems, and any other constitution symptoms is needed to make an accurate diagnosis. A thorough clinical examination to identify any abnormalities in neurological function or signs of nerve root compression can separate routine benign conditions from those putting the nervous system in peril.
A history of progressive pain unrelieved with rest or worse at night, fever, weight loss, previous diagnosis of cancer, immune compromise, tuberculosis, bacterial infection, trauma, osteoporosis, advanced age, weakness or numbness, loss of bladder or bowel control, and/or loss of erection are among the symptoms that may immediately point to a serious condition needing imaging investigation and other testing.
The intensity or severity of the pain itself is not often a useful indicator of the diagnosis.
Generally speaking, there are three different types of pain associated with spine pain. They are:
Mechanical Spine Pain:
- Injury or inflammation in the soft tissues of the body can cause a release of chemical substances which can incite a further inflammatory reaction which propagates itself locally. Injury to the muscles or tendons connected to the bony elements of the spine can trigger this reaction causing severe spasm of the spine and pain. This chemical reaction involves the release of substances called prostanoids which react with an enzyme, cytochrome c oxidase, then setting off a self-perpetuating cascade thereby amplifying the pain. This type of pain often responds to NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) which can reduce this chemical response and hence bring down the pain.
- This pain gets worse with weight bearing and movement of the spine. Typically it is limited to the vicinity of the spine and does not radiate to the extremities. Limitation of weight bearing and movement may provide some temporary relief.
- Like sprains and strains in other parts of the body, the initial period of immobility should be followed by a gradual stretching and strengthening program to facilitate restoration of function. Most often there is no significant anatomical damage to the spine. Patients can be treated conservatively.
- The spine is a collection of joints supporting the body while at the same time allowing movement. This movement can occur because the spine is composed of many bones which can move relative to one another in bending, twisting, and extending directions. However, since there are nerves passing between the bones this movement must be safely restricted to prevent compression of the nerves which could cause pain, weakness, numbness or even paralysis.
- There are two main structures which control this movement. The facet joints are bony plates attached to the vertebrae which block excessive movement in some directions while allowing more movement in other directions. Situated between the vertebrae is a shock absorber, the intervertebral disc, made of a tough outer layer of fibrous tissue and an inner layer of a normally well-hydrated matrix of protein and carbohydrate.
- Both the facet joints and intervertebral disc, like other joints in the body, can generate pain from tiny sensory nerves that detect injury, inflammation, or aging changes. These nerves are branches of the nerves that go to the extremities so that the brain may read a signal from these nerves as coming from the leg in the lumbar spine or the arm in the cervical spine.
- Pain in the extremity coming from the facet or disc typically is not as severe as the associated mechanical pain. Thus the neck or low back pain will be worse than the arm or leg pain present. Patients usually report that they cannot localize the pain exactly and it tends not to follow known distributions of nerve sensation called dermatomes. As the nerve itself is functioning normally and just doing its job, clinical examination and testing will not show an abnormality.
- This type of pain is often associated with tears of the outer disc or soft tissue injury or inflammation of the facet capsule covering the facet. It tends to be long lasting than mechanical pain and may require more intense rehabilitation such as physical therapy and learning to use one's body properly. For some, the onset of this pain may necessitate some permanent lifestyle changes if they are involved in jobs like heavy weight lifting. Surgery for this type of pain is rarely successful in making patients totally pain free.
Radiculopathy and Myelopathy:
- Compression of a nerve going to the arm in the cervical spine or the leg in the lumbar spine can lead to pain radiating from the spine to the extremities. Often this pain will be greater than the pain localized to the spine. Clinical examination of nerve function will often reveal a disturbance in sensation, strength or reflexes. Specific clinic maneuvers such as compression of the head for neck pain or lifting the leg passively for the lumbar spine worsen the pain due to radiculopathy.
- The spine has two channels through which the neural elements (nerves) pass. There is a large central canal for the spinal cord carrying all nerves from the brain to the rest of body and in between the vertebrae on each side, a smaller channel called the foramen, for the individual nerves going to the arm in the cervical spine and to the leg in the lumbar spine. The spinal cord ends at the upper level of the lumbar spine so that compression of the spinal cord occurs mostly in the cervical and thoracic regions.
- Compression of the spinal cord (myelopathy) generally results in an increase in reflexes while compression of nerve roots causes a loss or decrease in the reflex of the affected nerve root or roots. If the central canal is involved there will usually be symptoms of both sides of the body including weakness, numbness, or difficulty in controlling urination or bowel movement whereas compression in the foramen (radiculopathy) causes one-sided and often single nerve root involvement. Combinations of central and foraminal compression also can occur.
- The vast majority of adult spine pain patients have degenerative conditions due to aging and repetitive injury from heavy occupations which cause the disks and facet joints to wear out. Rarely these processes may result in nerve compression but usually are limited to causing only mechanical pain or pseudoradiculopathy which do not require surgery.
Following a thorough history and physical examination, which does not elucidate any warning signs or neurological involvement most adult patients can safely be treated conservatively for at least a month before undergoing expensive imaging such as an MRI. However, it should be noted that in regions where tuberculosis is endemic it may be wise to go for an x-ray of the spine and an ESR (Erythrocyte Sedimentation Rate), which together approach a 90 percent effective low-cost screening for tuberculosis of the spine.
Patients with warning signs in the history or clinical evidence of neurological compromise can consult a neurosurgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon
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