NECK AND BACK PAIN

PATIENT INFORMATION

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NECK AND BACK PAIN

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3D"Text 3D"Text VERTEBRAL COLUMN

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What is it?

Neck and back pain are comm= on health problems in adults. Some pain may be temporary, (like the one after = an intensive workout or after standing for a long time), yet some pain becomes permanent, due to a serious injury or medical condition. A significant number of neck and b= ack pain cases are signs of nerve root damage – with more than 30 pairs of nerves emerging from the spinal column and spreading as far as shoulders and toes, there is a considerable chance that at some point one or more of these nerves or their respective roots will be affected.

Despite its structural rigidity, our spinal column is not indestructible. Most of the damage is the result of compression or stretching of delicate nerve roots or surrounding structures= . Normal spine and nerve root anatom= y and function may also be affected by a variety of diseases or conditions, such = as:

1. = Infection

= a. = s= yphilis

= b. H= IV

= c. = m= eningitis

= d. L= yme Diseases (caused by spirochete Borrelia burgdorferi)

= e. = H= erpes Zoster, or shingles (caused by the varicella zo= ster virus)

2. = Inflammation, which results in swelling or loss= of tissues surrounding the nerve roots

= a. = a= cquired demyelinating poluradiculo= pathy

= &nb= sp; = &nb= sp; = &nb= sp; i. &nb= sp; acute form, called Guillian-Barre syndrome

= &nb= sp; = &nb= sp; = &nb= sp; ii. &n= bsp; chronic form, called chronic inflammatory demyelinating poluradiculopathy<= /p>

= b. a= bscess

= c. = i= nflammation of blood vessel walls, or vasculitis, resulting i= n loss of blood supply

3. = Degeneration of vertebrae and discs, deformation or compression

= a. = t= rauma

= b. h= erniated or ruptured disc

= c. = a= bnormally narrow spinal canal

= d. v= ascular disorders (problems with blood supply to the spinal cord and surrounding structure)

= &nb= sp; = &nb= sp; = &nb= sp; i. &nb= sp; loss of blood supply, or infarction

= &nb= sp; = &nb= sp; = &nb= sp; ii. &n= bsp; blood vessel rupture and resulting blood spilla= ge, or hemato= mas

= &nb= sp; = &nb= sp; = &nb= sp; iii. &= nbsp; bulging blood vessel, or aneurysm

= e. = a= ging

= f. = intensive, repetitive motions

= &nb= sp; = &nb= sp; = &nb= sp; i. &nb= sp; occupational hazards

= &nb= sp; = &nb= sp; = &nb= sp; ii. &n= bsp; sports (for instance, golf or tennis)

= g. = a= bnormal posture

= &nb= sp; = &nb= sp; = &nb= sp; i. &nb= sp; occupational hazards

= &nb= sp; = &nb= sp; = &nb= sp; ii. &n= bsp; life-style hazards

= h. o= besity

= i. = secondary to other diseases and conditions, such as:

= &nb= sp; = &nb= sp; = &nb= sp; i. &nb= sp; arthritis and other autoimmune causes

= &nb= sp; = &nb= sp; = &nb= sp; ii. &n= bsp; tumors and/or radiation therapy

= &nb= sp; = &nb= sp; = &nb= sp; iii. &= nbsp; diabetes

= &nb= sp; = &nb= sp; = &nb= sp; iv. &n= bsp; exposure to toxic chemicals

= &nb= sp; = &nb= sp; = &nb= sp; v. &nb= sp; hereditary disorders of nerve roots<= /span>

Signs and symptoms.

I.   &nb= sp;        Radiculopathy

The term radiculopathy (literally means “abnormality of the root”) is used to describe conditions when abnormalities in the anatomy of the spinal column irritate or compress the nerve roots. Symptoms of radiculopathies include:

1.      =              Pain

2.      =             Sensory changes

= a.      = e= xaggerated sensation, or hyperesthesia

= b.      l= oss of sensation, or anesthesia

= c.      = o= ther abnormal sensations, or paresthesia

      =             &nb= sp;            =             &nb= sp;            =             &nb= sp;     i.   &nb= sp; numbness

      =             &nb= sp;            =             &nb= sp;            =             &nb= sp;   ii.   &n= bsp; tingling

      =             &nb= sp;            =             &nb= sp;            =             &nb= sp; iii.   &= nbsp; burning

3.      =             Muscle changes

= a.      = w= eakness with no changes in size

= b.      e= xtreme weakness with decrease in size, or = atrophy

= c.      = i= ncreased muscle tone with no changes in size (muscle stiffness)

= d.      i= ncreased muscle size, or hypertrophy

Location of pain, sensory changes and muscle weakness is determined = by the location of the damaged nerve root:<= /p>
<= o:p>

D= amaged nerve roots in the neck area (nerve roots exiting the spinal cord between cervical vertebrae) cause cervical radiculopath= y, which brings about pain, sensory changes and muscle weakness in the neck, shoulder and arms.

D= amaged roots in the chest and trunk area (nerve roots exiting the spinal cord betw= een thoracic vertebrae) cause thoracic radiculopath= y, which brings about pain, sensory changes and muscle weakness in the rib cage and abdomen area.

<= o:p>

D= amaged roots in the lower back area (nerve roots exiting the spinal cord between l= umbar vertebrae) cause <= span style=3D'color:red'>lumbar radiculopathy, which brings about pain, s= ensory changes and muscle weakness from the lower abdomen area down to the calf ar= ea and may result in difficulty moving toes.&= nbsp; Rarely lumbar radiculopathy results in the enlargement, rather than weakness and atrophy, of select thigh and foot muscles.

            =     Damaged roots in the pelvis area (nerve roots exiting the spinal cord between s= acral vertebrae) cause sacral radiculopathy<= /span>, which brings about pain, sensory changes and muscle weakness from the lower back all the way down to the toes and sole. Rarely sacral radiculopathy result= s in the enlargement, rather than weakness and atrophy, of select foot muscles.<= span style=3D'mso-spacerun:yes'> A well-known example of sacral radiculopathy is sciatica, when pain (often excruciating) is felt in the buttock and down the back of = the leg.

Bladder, bowel and sexual functions may be impaired when nerves from the lower thoracic, lumbar and sacral roots are affected.

Spinal disc degeneration and spondylosis

Beginning in the 4^{th
and 5^th decades of life, discs become softer than they were in =
the
preceding years and are not, therefore, able to maintain their shape. Under the weight of the spine, the=
se
discs, particularly the ones between neck (cervical) and lower back (lumbar)
vertebrae, are liable to bulge out (or herniate) of the normally confined space bet=
ween
the vertebrae. As a result, this abnormally bulging disc will
“follow” the path of least resistance, which tends to direct the
herniation in the direction of the spinal cord and/or nerve roots.}

When these degenerative cha= nges are also accompanied by arthritis changes in the joints between the vertebra and the discs, a condition termed <= span style=3D'color:red'>spondylosis is recognized. Local arthritic changes only add t= o the damage that can be caused by a abnormal, bulging= disc that in impinging on the spinal cord or nerve roots. Pain experienced in this condition= is often characterized as knifelike, and can be felt as deep pain, coming from the muscles and bones innervated by t= he impinged or compressed nerve root.

Diabetic polyradiculoneuropathy

Older patients with diabetes (with or without treatment) often suffer from damage to nerve roots due to abnormalities in body metabolism. In many patients, symptoms of nerve root damage occur rather abruptly and start on one side of the body.   Pain in the trunk may be sha= rp, burning or throbbing, and may stereotypically be mistaken for acute cardiac= or abdominal medical emergencies. Sensory symptoms are represented by heightened sensitivity to touch = or patches of loss of sensation. Localized muscle weakness in the abdomen may lead abdominal swelling= .

With time (several weeks), these symptoms may spread and remain on one side, or may spread onto the ot= her side of the body. Muscle weak= ness develops and may vary (indeed as can any other symptom!) in its severity fr= om mild to severe. A rare occurr= ence is a dramatic spread of nerve root involvement from cervical to lumbar vertebrae, which leads to profound generalized weakness, fatigue, loss of appetite and loss of weight (called diabetic cachexia).

With treatment, most patien= ts experience improvement, but complete disappearance of pain and full recover= y of sensation and muscle tone may not be achieved.

Herpes Zoster, or Shingles

This is a fairly common (affects up to 20% of all people) condition caused by the varicella zoster virus, which can colonize nerve roots and remain dormant for many ye= ars, until it is reactivated, either spontaneously or by the immune system.

The disease is characterize= d by painful rash (which subsequently transforms into small vesicle that eventua= lly burst) that appears in areas innervated by the affected nerve roots – from face, to neck, to trunk, lower back and all the way to legs. The incidence of this disease tend= s to increase with age and weakened immune system. In the matter of 2-3 weeks most sy= mptoms and rash resolve, but not always: an area of reduced sensation may be left and sharp, burning or stubb= ing pain may persist for months.

Weak immune system created favourable conditions for the spread of the virus to other nerve roots, to other organs outside of the nervous system (lungs, heart, and gastrointesti= nal tract) and sometimes to the eyes.

Neoplastic polyradiculoneuropathy

Already diagnosed solid tum= ors (such as carcinoma of the breast, of the lung and melanoma), as well as non-Hodgkin’s lymphomas and leukemias may be complicated by nerve root damage. However, with the ons= et of radiculopathy symptoms, nerve root damage may be diagnosed before anyone knows about the malignancy. Often, when the membranes covering the spinal cord are affected and become inflamed (meningitis), stiffness of the neck muscles, confusion and = spread of symptoms to the face are noted.

II.   &n= bsp;      Plexopathy

Symptoms similar to radiculopathy may occur when a nerve plexus is affected. Such condition is called a = plexopathy. A nerve plexus is a web-like confl= uence of nerves that originated from several nerve roots as follows:

Nerves from roots C5 throug= h T1 combine to form the brachial plexus, located just above the clav= icle.

Nerves from roots L5 throug= h L5 combine to form the lumbar plexus, located in the lower back are= a, just above the pelvis.

Nerves from roots L4 throug= h S3 combine to form the sacral plexus, located in the pelvis. Roots L4 and L5 contribute to both lumbar and sacral plexus.

Despite symptomatic similarities between radiculopathies and plexopathies, there are important differences – sensory abnormalities, muscle weakness and motion restriction are more prominent in plexopathies than in radiculopathies.

DIAGNOSIS AND TREATMENT

Neurological Examination

A thorough specialized neur= ological examination is necessary to determine where the damage occurred - as nerves leave the spinal cord, they diverge and converge several times into roots a= nd plexi and thus form a complex web of nerve fibers.

Laboratory Testing

Chemical profile, complete blood count, endocrinologic= al tests, urinalysis, toxicology testing may be indicated particularly when symptoms are suspected to be secondary to other diseases, conditions or exposure to neurotoxins.

Biopsy

Biopsy of a nerve may be performed to discover any changes in the structure of the nerve.=

Lumbar Puncture

Sampling of the fluid that surrounds the brain and the spinal cord may be indicated, for instance, to reveal abnormal content of metabolites or presence of infectious agents.

Electrodiagnostic Testing

Electromyography (EMG) and Nerve Conduction Studies (NCV) assess nerve and muscle function and are very helpful for several reasons:

1.      =              To differentiate plexopathy fr= om radiculopathy

2.      =             To help localize nerve damage=

3.      =             To determine any concurrent problems with nerve fibers

4.      =             To determine what type of plexopathy a patient might have

Neuroimaging Studies

Imaging studies assess the structure of an organ or area in question.

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>1.      =              X-Ray

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>2.      =             Computer Tomography (CT)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>3.      =             Magnetic Resonance Imaging (MRI)

<= span style=3D'font-size:10.0pt;font-family:Georgia;mso-fareast-font-family:Georg= ia; mso-bidi-font-family:Georgia'>4.      =             Contrast studies (special dyes are administered either orally or intravenously)

IT IS VERY IMPORTANT TO SEE A QUALIFIED PHYSICIAN AND NOT = TO DELAY DIAGNOSIS AND TREATMENT WHEN ANY OF THESE SYMPTOMS APPEAR.   WHAT MAY SEEM I= N THE BEGINNING LIKE AN ANNOYING (BUT EASILY BEARABLE) DISCOMFORT MAY BE A SIGN O= F A SERIOUS CONDITION, WHICH, IF IGNORED, MAY LEAD TO EXTENSIVE TREATMENTS AND ACTIVITY-RESTRICTING CONSEQUENCES. &n= bsp; IT IS CRITICAL THAT THE CAUSE OF PAIN BE ESTABLISHED AS EARLY AS POSSIBLE.