Fast Five Quiz: Back and Neck Pain

Stephen Kishner, MD, MHA


June 11, 2020

The prevalence of low back and neck pain, which are thought to be associated with degenerative changes in the intervertebral disk, represents a major epidemiologic problem. Although sagittal alignment, facet joint arthritis, and genetics potentially play a role in intervertebral disk degeneration, the rate of degeneration may be associated with age. Individuals with African ethnicity have demonstrated a faster rate of degeneration when compared with white persons; sex has not shown a significant effect on degeneration.

The cascade of degenerative changes seen in degenerative disk disease can be subdivided into three stages:

  • Dysfunction

  • Instability

  • Restabilization

The duration of the stages varies greatly, and distinguishing the signs and symptoms from one stage to the next is difficult. The dysfunction stage involves outer annular tears and separation of the endplate, cartilage destruction, and facet synovial reaction. The symptoms of dysfunction are low back pain or neck pain, often localized but sometimes referred, and painful movement. The signs are local tenderness, contracted muscles, hypomobility, and painful extension of the back, neck, or both. Results of a neurologic examination are usually normal. In the instability stage, disk resorption and loss of disk space height occur. Facet capsular laxity may develop, leading to subluxation. The symptoms are those of dysfunction. The signs are abnormal movement (ie, during inspection or palpation), including observation of a catch, sway, or shift when standing erect after flexion.

MRI is the most comprehensive imaging modality for providing accurate, reliable, and detailed anatomic information in degenerative disk disease. In the absence of MRI, CT scanning is accurate in diagnosing disk herniations because of the contrast between herniated disk material, perineural fat, and the adjacent posterolateral margins of the bony vertebrae. However, MRI remains the imaging modality of choice for diagnosing lateral herniations.

Seronegative spondyloarthropathies are common causes of back pain and should be excluded. Assess for ankylosing spondylitis, reactive arthritis (formerly called Reiter syndrome), psoriatic arthritis, and inflammatory bowel–associated arthritis. Serum IgA is elevated in some patients with disk degeneration.

Conservative treatment of degenerative disk disease includes:

  • Education

  • Exercise

  • Medications

  • Physical modalities

  • Injections

Surgical treatment is used in approximately 5% of patients and includes:

  • Lumbar procedures

  • Cervical procedures

Lumbar surgery is indicated in the following patients:

  • Those with severe spinal stenosis

  • Those with intractable pain

  • Those in whom an appropriate 6- to 12-month nonoperative course of treatment fails

Surgery is elective, except in the presence of bowel and bladder symptoms or cauda equina syndrome.

In the case of cervical disk disease with radiculopathy, the indications for surgical treatment are:

  • Intractable pain

  • Progressive motor or sensory deficit

  • Symptoms refractory in a reasonable period of nonoperative therapy

Read more about degenerative disk disease.

This Fast Five Quiz was excerpted and adapted from the Medscape Drugs & Diseases articles Mechanical Low Back Pain, Cervical Sprain and Strain, Degenerative Disk Disease, and Cervical Spondylosis.

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