Spine

The vertebral column consists of 33 vertebrae—7 cervical, 12 thoracic, 5 lumbar, 5 sacral , and 4 coccygeal vertebrae—and 23 intervertebral disks. The spinal column is composed of four balanced curves: a cervical lordosis, a thoracic kyphosis, a lumbar lordosis, and a sacrococcygeal kyphosis. The compensatory nature of the balanced spinal curves allows the normal resting, erect posture to be maintained with minimal muscular effort.

History and Physical Examination

Categorizing patients with spinal pain into one of three broad groups can be particularly useful both diagnostically and therapeutically:

Mechanical, spine-predominant (neck or low back) pain
Neurological, extremity-predominant radicular (arm or leg) pain
Spinal pain associated with another specific etiology

It is crucial to focus the initial history on the one problem that accounts for more than 80% of neck and back symptoms: mechanical, spine-predominant (neck or low back) pain. Mechanical pain can be defined as symptoms arising from the irritation of a physical element or elements within the spine, predictably aggravated and relieved by specific movements and positions. It is the result of an anatomic malfunction unrelated to infection, neoplastic disease, systemic illness, or major trauma. An additional 10% of patients may present with symptoms of nerve root irritation with neurological, extremity-predominant radicular (arm or leg) pain.

Risk Factors for Potentially Serious Disease in Spinal Pain

Possible Cause	Key History and Examination Findings
Cancer	History of cancer with new episode of spine symptoms Unexplained weight loss Disproportionate night pain or constant pain at rest Lack of treatment response Failure to improve after 1 month Age > 50 years
Vertebral infection	Fever Recent infection Intravenous drug use Immunocompromised
Vertebral compression fracture	Thoracic-dominant pain History of osteoporosis Corticosteroid use Minor trauma (in patients age > 70 years)
Spondyloarthropathy	Morning stiffness Improvement with exercise Alternating buttock pain Awakening with back pain during the second half of the night Onset age < 40 years
Visceral disease (referred pain)	Aortic aneurysm Pulmonary, cardiac/pericardial, GI, or GU disease

Common Painful Disorders of the Spine

Acute, Uncomplicated, Mechanical Neck and Low Back Pain

Acute, uncomplicated, mechanical neck and low back pain accounts for the vast majority of spinal pain seen in clinical practice. The clinical history is important, and with a mechanical presentation in the absence of radicular or serious underlying conditions, the diagnosis of acute mechanical neck or low back pain is acceptable. A definitive anatomic diagnosis cannot be established in up to 85% of patients presenting with acute low back pain. Up to two thirds have resolution of their symptoms in 4 to 8 weeks, although recurrences are likely.

Acute, Mechanical Low Back Pain

This is commonly referred to as lumbosacral sprain, although there may be no evidence of ligamentous injury. Acute low back pain is a common, usually self-limiting but frequently recurrent problem. The pain may be precipitated by lifting or bending, although in the majority of cases, there is no specific triggering event. Physical examination reveals diffuse lumbar spine tenderness, muscle spasm, and diminished ROM without radicular symptoms or signs. Whether the pain originates in the paraspinal muscles, ligaments, disks (annular tears), facet joints, or other structures is not clear and usually is not clinically relevant. Although up to 85% of patients may return to normal activities within 2 months, recurrences may occur in up to 75% of patients within 12 months.

Chronic Neck and Low Back Pain

Neck and low back pain persisting beyond 3 months despite conservative management develops in a minority of patients and represents a significant clinical and economic problem. Important historical features may relate to the patient’s work, home, personal, and psychosocial history.

Cervical Degenerative Spondylosis

Degenerative changes of the vertebral bodies, secondary to cervical degenerative disk disease or uncovertebral and facet joint osteoarthritis, are referred to as cervical spondylosis. It commonly occurs in older individuals and is related to the loss of integrity of the intervertebral disk, secondary osteoarthritic changes in the uncovertebral and apophyseal joints, and hypertrophy and redundancy of the ligamentum flavum. It is important to note that the presence or degree of cervical degenerative spondylosis on imaging does not necessarily correlate with the presence or severity of neck symptoms.

Cervical Radiculopathy and Myelopathy

Neck pain combined with neurogenic upper-extremity pain strongly suggests cervical nerve root irritation. Pain may also radiate along the mid-scapular region. Far less common than uncomplicated mechanical neck pain, cervical radiculopathy usually results from disk herniation associated with facet and uncovertebral osteophytes causing mechanical or chemical irritation of the nerve root and its dural attachment as it enters the neural foramen. Radiating pain can often be reproduced or intensified with manual cervical compression or distraction maneuvers. Thoracic spine pain with radiation around the ribs likewise suggests thoracic radiculopathy.

Lumbar Degenerative Spondylosis

Degenerative changes in the vertebral bodies, secondary to lumbar degenerative disk disease and facet joint osteoarthritis, are commonly referred to as lumbar spondylosis. It typically occurs in older individuals and is related to intervertebral disk degeneration and osteoarthritic changes in the lower lumbosacral facet joints and sometimes to degenerative spondylolisthesis. Chronic low back pain with radiation to the buttocks is the most common symptom.

Lumbosacral Radiculopathy

Low back pain combined with neurogenic lower extremity pain (sciatica) strongly suggests lumbosacral nerve root irritation. Pain may be abrupt or gradual in onset, and it typically radiates from the buttock to the posterior or posterolateral thigh or to the ankle or foot. There may be accompanying lower-extremity numbness, tingling, or weakness. Almost 85% of lumbosacral disk herniations involve the L4/L5 (L5 nerve root) or L5/S1 (S1 nerve root) level. In most cases symptoms resolve without the need for surgery, although symptoms persist longer than typical mechanical low back pain.

Acute, severe low back pain with bilateral sciatica, saddle anesthesia, and recent-onset urinary dysfunction (retention, overflow incontinence) and/or loss of rectal sphincter tone strongly suggests a cauda equina syndrome.

Degenerative Lumbar Spinal Stenosis

Degenerative lumbar spinal stenosis is a relatively common cause of neurogenic lower-extremity pain in older individuals. Varying combinations of degenerative disk disease with loss of disk height, redundancy and hypertrophy of the ligamentum flavum, and occasionally degenerative spondylolisthesis lead to narrowing of the spinal canal with lateral recess or foraminal stenosis at multiple levels. Freedom from or improvement of symptoms during exercise in a flexed position (walking uphill, bicycling) helps differentiate degenerative spinal stenosis from vascular claudication. Physical findings can include posterior thigh pain and transient motor weakness after 90 seconds of forced spinal extension, a wide-based gait, abnormal motor or sensory testing, and normal lower-extremity pulses. The physical examination is typically normal with the patient at rest, and the diagnosis is made primarily on the patient’s history. Differential diagnosis includes hip disease, trochanteric bursitis, and peripheral neuropathy.

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