When you consider how intricate the construction of the spine is and how varied are its components, you can readily understand why neck and back problems are so common and widespread.
This chapter examines what can go wrong with each of the parts that make up the spine and its related structures and gives examples of conditions that can occur because of departures from normal functioning. These disorders are discussed in detail in the chapter on ailments, in which treatment options are also suggested.
Not all back and neck pain is experienced as a result of an injury or repetitive strain. Pain can occur as a result of a problem elsewhere in the body, such as a bladder infection, stomach ulcer or even psychological complications.
Back and neck pain can occur because of biomechanical problems such as compression of intervertebral discs, torsion (twisting) injury and vibration, such as that produced by some types of tools (jackhammers, for example). People whose occupations require strenuous or repetitive lifting in a stooped position are most at risk of experiencing these difficulties.
Spinal pain can also be a result of destructive forces that occur in infections, tumours and rheumatoid disorders such as arthritis and ankylosing spondylitis.
Degenerative changes, as seen in osteoporosis and spinal stenosis (narrowed spinal canal), are other sources of back and neck pain. Because osteoporotic bones are not as strong as healthy ones, they are more vulnerable to collapse, causing pressure on nerves, which in turn may produce pain. In spinal stenosis, the narrowing of the canal through which the spinal cord runs, and consequent compression of nerves, is what generates pain.
Back and neck pain can be associated with a number of health disorders not originating in the spine. These include:
Stomach or duodenal ulcer
Inflammation of the pancreas (pancreatitis)
Enlarged abdominal aorta (large artery)
Bladder or kidney infection
Gynaecological conditions such as fibroids, endometriosis, dysmenorrhoea and pelvic infection
Pregnancy-related problems including ectopic pregnancy (occurring in an abnormal position)
Pain originating from psychological sources, such as depression, a significant personal loss or other life crisis, is yet another cause of spinal problems. This may be explained, in part, by the way the brain processes pain and by the suppression of endorphins, which are the body’s own pain-relievers.
Of all the conditions that can trigger neck and back pain, there are some that signal serious health disorders. They are therefore called ‘red flags’ and they require urgent medical attention. They include:
Recent major trauma such as injury from a car accident or sports event
Pain that worsens at night or when you lie down
Fever which cannot be explained
Weight loss or gain which cannot be explained
A history of cancer, diabetes, kidney disease or osteoporosis
Below is a list of the various parts that make up the spine and examples of what can go wrong with each of them. Later in the chapter, we look at diagnostic procedures that help to identify specific disorders.
| SPINAL CORD AND NERVES Spinal cord damage Irritation (of the sciatic nerve, for example) leading to sciatica Inflammation Compression of nerves Impingement on nerves (as in spinal stenosis) Cauda equina syndrome |
DISCS Herniation (as may occur in the cervical vertebrae in whiplash) Degeneration Strain |
TENDONS Tendons are vulnerable to the same injuries as ligaments (below left). |
| BONES Bruises Fractures Trauma (as from a fall) Loss of bone mass (as in osteoporosis) Infection Malignancy |
ABNORMAL SPINAL CURVES Scoliosis (lateral spinal curvature) Lordosis (abnormal forward curve of the lumbar spine) Kyphosis (posterior curvature of the thoracic spine; hump-back, as is sometimes seen in osteoarthritis) |
MUSCLES Muscle spasm (as sometimes occurs in whiplash) Strain Tears Tightness Inflammation Overuse |
| JOINTS Degenerative changes (as in osteoarthritis) Strain Slippage (as in spondylolisthesis) Cumulative stress Poor posture Swelling Strain or arthritis of the facet joints |
LIGAMENTS Tears Strain Sprain Trauma (as may be sustained in a sports accident) Cumulative stress (repetitive strain) Pregnancy-related (lax sacroiliac ligaments, due to hormonal influence) |
MULTIPLE STRUCTURES The following conditions can affect various spinal structures: Whiplash Degenerative changes Inflammation Instability (such as the slippage that occurs in spondylolisthesis) |
In order to identify the cause and nature of your back and neck pain and associated symptoms, your doctor may order one or more of a number of tests. These are used to confirm a diagnosis based on a physical examination. They may also be done to rule out certain other suspected disorders, or as part of preparation for surgery. In addition, they are useful in helping to plan treatment. The following are some of the more common procedures in current use.
Instead of X-rays, this test uses changing magnetic fields to provide images of various body structures. Tissues in different parts have different resonance properties. Changes in these properties occur in disease states such as inflammation. MRI scans are useful in their detection.
MRI provides an excellent picture of the spine and also of soft tissues such as discs, muscles and ligaments. It is therefore very useful for evaluating conditions such as a narrowed spinal canal (spinal stenosis), spinal cord damage, infection and tumours. It is also of value when surgery is being contemplated for spinal stenosis and some cases of disc herniation.
The procedure requires you to lie very still for perhaps an hour, in a small tube, and you will be screened in advance for the presence of any metallic device or objects in your body. People with claustrophobia may be given anxiety-relieving medication.
MRI MAY BE ORDERED FOR
• Emergency evaluation of Cauda Equina Syndrome
• Progressive neurologic symptoms
• Symptoms suggesting infection or tumour
• Evaluation of spinal stenosis pre-operatively
• Evaluation of disc herniation pre-operatively
• Evaluation of degenerative changes in recurring or persisting back pain
MRI IS NOT ADVISED
• In pregnancy
• Following recent blood vessel surgery
• In severe claustrophobia
• In the presence of a heart pacemaker or metal objects in the body
Plain X-rays of the spine show the spinal column, sacrum and sacroiliac joints. They are useful in assessing bone quality and revealing arthritic changes and narrowed disc spaces. Your doctor will probably order a plain X-ray in the following instances:
• Red flag conditions
• Severe injury and suspected fractures
• A history of osteoporosis or cancer
• Severe pain at night, which worsens or is unrelieved by rest
A plain X-ray may also be ordered if you report:
• Persisting back pain
• Symptoms suggesting unstable vertebrae (‘catching’)
• Suspected arthritic changes, such as pain and impaired function
X-rays are not advisable during pregnancy because of possible damage to the foetus.
Formerly called a CAT (Computerized Axial Tomography) scan, this procedure uses regular X-rays to provide a three-dimensional image of body structures. It is a painless procedure that requires the client to be on a platform that passes through a horseshoe-shaped gantry (special supporting structure).
The CT scan provides good visualisation of bony structures and also of soft tissues such as nerves, discs and ligaments. It is therefore useful in identifying conditions such as spinal stenosis, disc herniation and nerve compression and bone erosions due to infection or tumour. It is also of value in the pre-operative assessment of some conditions, such as spinal stenosis due to arthritis.
Post-operatively, a CT scan helps the surgeon to assess correct placement following the implantation of hardware such as screws and plates – in spinal fusion, for example.
Although exposure to radiation is minimal, a CT scan should be used with caution, if at all, on pregnant women.
This test measures bone cell activity. It requires the injection of a harmless radioactive marker into a vein in the hand, followed two hours later by a scan of the whole body or a specific part. Active areas show up as ‘hot spots’.
This bone scan is very sensitive in detecting fractures and it can pick up minor bone injuries not visible on X-rays. It can help to distinguish an acute fracture from an old one. It is also a sensitive test for the presence of infection and tumour metastases. It can, in addition, reveal the presence of osteoporosis.
As with other tests that involve radiation, the isotope bone scan is not advised during pregnancy.
Myelography requires the injection of a radiopaque dye into the sheath containing the spinal cord and nerve roots. The dye facilitates imaging. Plain X-rays are then taken. The procedure is useful in assessing conditions such as nerve compression and spinal cord abnormalities.
Myelography necessitates the insertion of a long needle into the back, and its side effects include headache and nerve irritation. Although it is sometimes used in conjunction with a CT scan, it has largely been replaced by MRI.
A SPECT scan works in a similar way to a regular bone scan, and like a CT scan it can give three-dimensional localisation. This has proven particularly useful in identifying arthritic facet joints prior to injection therapy, and for postoperative evaluation of spinal fusion.
The SPECT scan does not replace a CT scan or an MRI, but it may be useful in acquiring more information about the precise location of a problem.
Discography requires the insertion of a needle into an intervertebral disc, with the help of X-ray guidance. This is followed by the injection of radiopaque dye and saline (salt water).
Discography is useful in the assessment of disc integrity and is usually performed without sedation or general anaesthesia because the patient must be sufficiently alert to report what he or she is feeling. Local anaesthetic, however, can be used on the skin prior to needle insertion.
Uses for discography include:
• Identifying the intervertebral disc as a cause of low back pain
• As an aid in predicting the probable outcome of certain invasive disc procedures
• As an aid in planning surgery and predicting its probable outcome
The following are some tests that may be ordered to help identify the source of neck and back pain (see also Glossary):
• CBC (complete blood count) and ESR (erythrocyte sedimentation rate) in the presence of red flag conditions, or when pain persists for several weeks
• CBC, ESR, C-reactive protein, TB test and blood cultures to help detect possible infection
• CBC, ESR, calcium phosphate, serum protein levels and analysis, liver enzymes, PSA (prostate gland screen) in men, to help detect possible malignancy
• CBC, ESR, rheumatology screen and HLA-B27 screen to help detect spinal pathology such as arthritis and ankylosing spondylitis
Certain nerve tests may be carried out either for purposes of diagnosis or for monitoring during major spinal surgery. They include:
• EMG (electromyography) to test the function of motor nerves, which enable muscles to contract
• SSEPs (somatosensory evoked potentials), which test the integrity of sensory nerves
• Nerve conduction tests, which examine the transmission speed of electrical impulses along a nerve