The following are the four sets of vertebrae that make up the spine:
- Cervical vertebrae (C segments): 8 segments of bone (vertebrae); C1-C8 spinal nerves.
- Thoracic vertebrae (T segments): 12 segments of bone (vertebrae); T1-T12 spinal nerves.
- Lumbar vertebrae (L segments): 5 segments of bone (vertebrae); L1-L5 spinal nerves.
- Sacral vertebrae (S segments, fused): 5 segments of bone (vertebrae); S1-S5 spinal nerves.
All of the things that can go wrong at the spine to create lower back pain can also occur at any other spinal level, so the thoracic and cervical levels are no exception. Since pain in the thoracic spine, which consists of the T1–T12 spinal nerves, is similar in respect to the pathology, diagnosis, and treatment options for lower back pain (at L1–L5), this discussion will center on the upper vertebral column, particularly the cervical segments at C1–8.
What causes upper back and cervical (neck) pain?
As was discussed in the last part of this series, the risks of developing pain at the cervical and thoracic levels are increased by the following:
- Herniated disc, compression of the spinal cord (spinal stenosis), or the cauda equina (termination of the spinal cord): These conditions can cause radiculopathy (nerve sensations radiating down the course of the nerve) due to damage or compression to the spinal nerve root.
- Osteoarthritis: Over time, this may lead to spinal stenosis.
- Ankylosing spondylitis: This is inflammatory arthritis of the spine. It may be a genetic predisposition.
- Tumors: Whether benign or malignant, any tumor will occupy space that results in compression.
- Vertebral facture resulting in compression (compression fracture): This is more likely to occur because of age, trauma, and/or with chronic use of steroids.
For the neck, another common cause is trauma. Added to the wear-and-tear of living life, working, and recreational exertions are high speeds and the neck’s tendency to not like stopping abruptly. Automobile accidents, sports collisions, and accidents that challenge the neck’s supportive infrastructure have increased the causes of neck pain over what was traditional for our species generations ago.
How are upper back and cervical pain diagnosed?
- For non-traumatic causes, a thorough medical history examination and a physical exam, including a range of motion (ROM) determinations, are essential. If the patient is over 50, an X-ray should be included in the evaluation.
- A thorough neurological evaluation is extremely important for the neck, as nerve compression there can lead to disabling symptoms of the limbs and even internal organs. Such symptoms include the following:
- Arm clumsiness;
- Difficulty walking;
- Bowel dysfunction;
- Bladder dysfunction;
There are eight cervical spinal nerves in the neck, and each influences muscles movement (motor) and sensation (sensory) from the areas that go with those nerves. Compression or injury can affect the motor or the sensory components individually or together. Such nerve compromise is called radiculopathy. Central compromise can affect any part of the body below its level.
- For traumatic causes, particularly those that are obvious from a patient’s medical history, imaging is helpful. MRI and X-rays can depict movement-misalignment among the bones from C1 to C5 and T1 to T12.
- When there are symptoms more in the extremities than in the neck, electromyography (EMG) can separate peripheral nerve entrapment from cervical radiculopathy (nerve involvement of the limb itself or higher up in the neck).
Age and degenerative diseases such as osteoarthritis, the former of which exacerbates the latter, and osteoporosis and osteomalacia can contribute to the development of neck pain. Although the degenerative changes are the most common cause for neck pain, something as traumatic as a car accident can be the biggest cause of cervical pain.
Concerns with acute neck pain conditions
- Because of the adjacent anatomy, any acute neck pain should prompt a physician to rule out serious infections, such as meningitis. Even dentistry is involved if there are throat lesions presenting as neck pain.
- Patients that have sustained an accident or fall should be immobilized until the extent of the injury can be determined.
- Cervical strain, which the injury of muscles and ligaments along the spine that can cause spasms going down the back, can last as long as 6 weeks.
- Cervical facet pain, which typical whiplash-related neck pain, can also be associated with headaches.
What about chronic neck conditions?
Aside from trauma and infections that cause acute conditions, chronic neck conditions, result from things such as the following;
- Cervical discogenic pain, such as cervical spondylosis (soft tissue, disc, and degenerative bony lesions) and disc herniation.
- Degenerative changes, which are normally seen in imaging on anyone over the age of 40.
- Rheumatoid arthritis, an autoimmune disease in which the joint of the spine is attacked.
- Cervical myofascial pain, which is muscle spasm with trigger points, caused by splining the muscles of the neck to sidestep the original pain. This can be caused by non-vertebral causes as well.
- Osteophytes, which are calcifications from inflammatory conditions.
Trauma, although a major cause of acute neck pain, may cause chronic neck pain to persist from the scarring the trauma caused all the way to the healing process.
How are acute and chronic neck pain treated?
The treatments for acute neck pain treatments are based on the cause. Therefore, acute neck pain caused by trauma requires immobilization, stabilization, and surgical intervention if warranted. Acute neck pain caused by infection, such as meningitis or abscesses, requires antibiotic therapy.
For chronic neck pain, treatments include the following:
- Active interventions: These interventions can include cognitive behavioral therapy (CBT); tai chi; yoga; and other MBSR (mindfulness-based stress reduction), including biofeedback.
- Physical therapy: This includes motor control exercises; core strengthening; flexion/extension movements; aerobic exercise; and mind-body exercise, such as yoga and Pilates.
- Ice massages: This stroking the neck muscles for 5–7 minutes at a time.
- Moist heat: Heat the afflicted area for 10–15 minutes at a time.
- Massages: These should be done after ice massages or moist heat treatment.
- Trigger point injections: This may help temporarily, but it does not speed up the recovery process.
- Pharmacologic therapy: This can be done if necessary or if previous interventions have failed. This type of therapy can involve the following medical substances.
- NSAID with a nonbenzodiazepine muscle relaxant, including the following:
- Cyclobenzaprine (Flexeril)
- Metaxalone (Skelaxin)
- Methocarbamol (Robaxin)
- Orphenadrine (Norflex)
- Tizanidine (Zanaflex)
- Non-opioid tramadol: Tramadol attaches to the opioid receptors on nerves, so it acts as a weak narcotic. It also increases serotonin, which is thought to enhance pain relief, but it must be used with caution if a patient is on an SSRI or SNRI antidepressant.
- Duloxetine (Cymbalta) increases serotonin.
- Medications with little or no benefit based on studies so far include the following:
- Gabapentin and pregabalin (Neurontin and Lyrica, respectively). These have shown small or unclear benefit(s).
- Herbal remedies.
- Acupuncture and massages: These may offer short-term relief, but studies are inconclusive on any long-term relief of either.
The following are either not recommended or beneficially limited chronic syndrome treatments:
- Cervical collar: This is not recommended because it may delay recovery or allow the neck muscles to weaken; an improper fit can make the neck pain worse.
- Interferential therapy, low-level laser therapy, ultrasound treatment, shortwave diathermy, TENS, and traction: All of these have limited or no benefits.
- Surgery: This is not beneficial, except in the case of relieving symptoms from a pinched nerve or herniated disc.
Nowhere is the interaction between the skeleton and the nerve tissue it protects and the support mechanism of muscles, ligaments, and tendons more mutually synergistic than in the neck. The combination of these different aspects of the anatomy presents a unique body structure that requires a unique approach to evaluation. Because of the precarious nature of the neck, which is continuous with the skull above and the rest of the body below, the spinal column in the neck is at particular risk to traumatic injury, which would only add to the degenerative actions already seen in areas of the back lower down.