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BACK AND NECK PAIN
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OBJECTIVES
Know and understand:
• The history and symptoms characteristically
associated with each systemic and nonsystemic
cause of back or neck pain
• The best methods of assessing back or neck pain
in older patients
• How to distinguish hip disease from back disease
as a cause of back pain
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TO P I C S C O V E R E D
• Introduction to Back Pain
• Causes of Back Pain
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Systemic Causes
Lumbar Spinal Stenosis
Sciatica
Unstable Lumbar Spine
Osteoporotic Vertebral Compression Fracture
Osteoporotic Sacral Fracture
• Assessment of Back Pain
• Management of Back Pain
• Neck Pain
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I N T R O D U C T I O N TO B A C K PA I N
• 3rd most common reason for physician visits by older
people
• Most episodes resolve in one month
• Most common cause: degenerative conditions of the
spine
• Less common causes, such as tumors, infections, and
visceral lesions, may require emergent treatment
• Imaging of lumbar spine commonly shows anatomic
abnormalities in older persons, but these may be
unrelated to pain
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S Y S T E M I C C A U S E S O F B A C K PA I N
• Tumors or infections of the spine—pain has insidious
onset, is more persistent with time, usually nonpositional, associated with systemic symptoms and
signs, often persists through night
• Vertebral infection—fever, discrete local vertebral
tenderness, upper lumbar or thoracic pain, nonpositional pain
• Visceral problems—suggested by the historical pattern
of pain, absence of positional changes, normal
physical exam of the lumbosacral spine
• Systemic causes merit immediate intervention
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LUMBAR SPINAL STENOSIS
• Flexion of the lumbar spine relieves symptoms;
extension exacerbates symptoms
• Pain is in either the back or the legs and is made
worse by standing or walking and relieved by sitting
• Symptoms are usually progressive and consistent
• Many patients have a “pseudoclaudication” syndrome
• There is often subtle weakness in muscles innervated
by the L4, L5, and S1 nerve roots
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S C I AT I C A
• Lancinating pain
 Usually from buttock down the posterior aspect of leg to foot
 May occur only in isolated regions
• Two common patterns in older persons
 Pain only with standing and walking—usually a result of
lumbar spinal stenosis
 Pain has relatively sudden onset, present at rest,
exacerbated by sudden maneuvers, persistent, not
necessarily related to the erect position—usually resolves
spontaneously in a few weeks
• Weakness of the L4, L5, and S1 innervated muscles of the
foot, ankle, and hip
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U N S TA B L E L U M B A R S P I N E
• Produced by lumbar degenerative disc disease
• Episodes of severe pain in the back or the distribution
of the sciatic nerve
• Pain usually is sudden, often following abrupt
movements
• Pain can come on with significant flexion or extension
of the lumbar spine
• On physical exam, patient often has guarded
movements of the lumbar spine and pain when moving
from the flexed to the extended position
OSTEOPOROTIC VERTEBRAL
COMPRESSION FRACTURES
• Less than one third of fractures are symptomatic
• Pain from acute fracture:
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Has abrupt onset
Is intense
Usually worsens on standing and sitting
Commonly radiates to flank, abdomen, and legs
Resolves slowly (approximately 1 mo restricted activity)
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OSTEOPOROTIC
SACRAL FRACTURES
• May account for lower back pain in older women
• Pain occurs spontaneously, usually in the lower
back but can occur in the buttock or hip
• High incidence of additional osteoporotic fractures
• Technetium bone scans and CT usually required
• Pain usually resolves in 4–6 weeks, but can be
more prolonged
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SUMMARY: CAUSES OF BACK PAIN
IN OLDER PERSONS (1 of 2)
Condition
History
Examination
Laboratory Tests, Imaging
Tumor
Persistent, progressive pain
at rest; systemic symptoms
No focal abnormalities
Anemia, elevated ESR,
abnormal bone scan or MRI
Infection
Persistent pain, fever; atrisk patient (eg, indwelling
catheter)
Tender spine
Elevated ESR, WBC;
positive bone scan or MRI
Unstable lumbar
spine
Recurring episodes of pain
on change of position
Pain going from flexed
to extended position
One disc space narrowed
and sclerotic
spondylolisthesis
Lumbar spinal
stenosis
Pain on standing and
walking relieved by sitting
and lying
Immobile spine; L4,
L5, S1 weakness
MRI or CT scan showing
stenosis
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SUMMARY: CAUSES OF BACK PAIN
IN OLDER PERSONS (2 of 2)
Condition
History
Examination
Laboratory Tests, Imaging
Sciatica
Pain in the posterior aspect
of leg; may be incomplete
Often positive straightleg raise; L4, L5, S1
weakness
Variable diagnostic imaging
findings
Vertebral
compression
fracture
Sudden onset of severe
pain; resolves in 4–6 weeks
Pain on any
movement of spine; no
neurologic deficits
Vertebral end-plate collapse;
compression fracture seen
on plain film
Osteoporotic
sacral fracture
Sudden lower back, buttock,
or hip pain
Sacral tenderness
H-shaped uptake on bone
scan
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ASSESSMENT OF LOWER BACK PAIN:
USING THE HISTORY
Symptoms
Acute pain
Conditions
• Vertebral compression fracture
• Disc displacement
• Osteoporotic sacral fracture
• Visceral pain (eg, aortic aneurysm)
Positional pain
• Increased with standing and walking and relieved with sitting—
lumbar spinal stenosis
• Brought on by bending, lifting, or unguarded movements—
unstable lumbar spine
Persistent pain
(gradually
increasing, nonpositional)
• Tumor
• Infection
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PHYSICAL EXAM
F O R B A C K PA I N
• Patient in upright position—move through the 4 planes
of movement of the lumbar spine
• Patient in supine position
 Straight-leg raise test
 Assess passive range of motion of the hip
 Examine muscles of the lower extremities
• Observe patient rising from a chair and walking
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ASSESSMENT OF LOWER BACK PAIN:
PHYSICAL EXAM
Sign
Condition
Paravertebral muscle spasm
• Mechanical disease
Asymmetric range of motion of the
lumbar spine
• Mechanical disc disease
Spinal tenderness
• Vertebral compression fracture
• Unstable lumbar spine
• Infection
Weakness of the L4–L5 and L5–S1
muscles
• Mechanical disc disease
Normal exam of the lumbar spine
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• Lumbar spinal stenosis
Osteoporotic sacral fracture
Hip disease
Tumor
Referred visceral pain
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H I P PA I N V S . B A C K PA I N
• Hip disease often mimics back disease, causing
pain in the back and leg
• Pain when moving from supine position to sitting,
or when bending or stooping—suggests back
disease
• Pain after prolonged sitting and when moving from
sitting to standing position—suggests hip disease
• Significant limp—suggests hip disease, except in
cases of significant sciatica
LABS & IMAGING
F O R B A C K PA I N
• In older patients, plain radiographs are the most useful
starting point
• Technetium bone scan—to evaluate suspected infection
or neoplasm
• CBC with ESR—most useful screening lab test for
underlying systemic disease
• CT or MRI needed to document spinal stenosis if surgery
is contemplated
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T R E AT M E N T O F
U N S TA B L E L U M B A R S P I N E
• Nonopioid analgesics in early stages
• Gentle, progressive exercise program once acute
symptoms subside
• If the patient’s pain appears to be exacerbated by
spinal movement, immobilize the spine by:
 Exercises to strengthen paraspinous and
abdominal muscles
 Lumbar sacral corsets and braces
• Consider surgical fusion in severe cases nonresponsive to conservative therapy
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T R E AT M E N T O F V E R T E B R A L
COMPRESSION FRACTURES
Analgesia is the most important goal
• Corsets
• Spinal extension exercises
• Calcitonin (off-label)
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T R E AT M E N T O F
LUMBAR STENOSIS
• Conservative therapy is limited
• Most common indication for spinal surgery in
older adults
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C A U S E S O F N E C K PA I N
• Mechanical diseases of cervical spine (most common)
 Neck and occiput pain
 Scapula and trapezius pain
 Radicular pain down the arm
 Spastic paraparesis
• Inflammatory conditions
 Morning stiffness
 Systemic complaints (eg, fatigue, fever)
 Muscle and joint complaints elsewhere in the body
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A S S E S S M E N T O F N E C K PA I N
• Mechanical disease of the cervical spine is demonstrated
if there is:
 Asymmetric limitation of range of motion in some but
not all of the 4 planes of movement
 Weakness of the upper extremity muscles innervated
by the cervical nerve root
• The role of imaging in diagnosis and management is
unclear
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M A N A G E M E N T O F N E C K PA I N
• Few good controlled studies
• Cochrane review:
 Combination of mobilization and/or
manipulation with active exercises beneficial
for persistent mechanical neck disorders
 Mobilization alone not effective without an
exercise program
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S U M M A RY ( 1 o f 2 )
• Back problems are the third most common reason
for physician visits by older persons
• Degenerative conditions of the spine are the most
common cause of back pain
• Consider tumor or infection if pain is insidious in
onset, progressive in its course, and nonpositional; is associated with night pain and
systemic symptoms or signs, and persists for more
than 1 month
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S U M M A RY ( 2 o f 2 )
• Nonsystemic causes of pain are characterized by
intermittent, often positional pain that is worse at onset
and usually improves with time
• Plain radiographs remain the most useful starting point
in a back pain work-up of an older patient
• Management of back pain requires addressing the
structural problems most likely to be causing the pain
• Neck pain is most often due to mechanical disease of
the cervical spine and is best diagnosed on physical
exam
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CASE 1 (1 of 3)
• An 81-year-old woman comes to the office because of
lower back pain for 2 weeks. The pain worsens when
she sits or stands but is relieved when she lies in bed.
History includes vertebral compression fracture 4 years
ago and right femoral neck fracture 2 years ago.
• On physical examination, straight-leg raise tests are
normal bilaterally. Strength of proximal and distal
muscles is 5/5 in both legs. There is good mobility of
the lumbar spine. The patient describes marked pain
when pressure is applied to the sacrum. Radiography
of the lumbar spine reveals diffuse osteoporosis and
multilevel degenerative disc disease.
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CASE 1 (2 of 3)
Which of the following is the most likely cause of
this patient’s pain?
A)
B)
C)
D)
E)
Lumbar spinal stenosis
Tumor affecting the lumbar spine
Osteoporotic sacral fracture
Lumbar disc disease
Osteomyelitis of the L4 vertebrae
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CASE 1 (3 of 3)
Which of the following is the most likely cause of
this patient’s pain?
A)
B)
C)
D)
E)
Lumbar spinal stenosis
Tumor affecting the lumbar spine
Osteoporotic sacral fracture
Lumbar disc disease
Osteomyelitis of the L4 vertebrae
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CASE 2 (1 of 4)
• An 81-year-old man comes to the office because he
has had pain in his right calf for 6 months. Initially, he
had pain after walking about one quarter mile, but
now he has pain after walking 100 ft or with
prolonged standing.
• The pain resolves completely when he sits. He has
had no pain in his back or upper leg.
• On examination, dorsalis pedis and posterior tibial
pulses are 2+ bilaterally. There is good hair growth on
both lower legs.
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CASE 2 (2 of 4)
• There is mild immobility of the lumbar spine.
• Straight-leg raise tests are normal bilaterally.
• He has mild weakness of the right great toe extensor,
right hip abductor, and right hip extensor.
• Lumbar spine radiography shows diffuse
degenerative disc changes throughout the lumbar
region.
• Doppler ultrasonography indicates normal arterial
blood flow.
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CASE 2 (3 of 4)
Which of the following treatments is most likely
to be effective?
A)
B)
C)
D)
E)
Arterial bypass of the lower leg
Angioplasty of lower leg vessels
Epidural corticosteroid injections
Laminectomy
Physical therapy
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CASE 2 (4 of 4)
Which of the following treatments is most likely
to be effective?
A)
B)
C)
D)
E)
Arterial bypass of the lower leg
Angioplasty of lower leg vessels
Epidural corticosteroid injections
Laminectomy
Physical therapy
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GRS Slides Editor:
Annette Medina-Walpole, MD, AGSF
GRS8 Chapter Author:
Leo M. Cooney, Jr., MD
GRS8 Question Author:
Leo M. Cooney, Jr., MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2013 American Geriatrics Society