Method
We suggest sorting the above disorders that cause neck and back pain
into 7 clinical groups according to several simple clinical, laboratory,
and imaging criteria that will enable us to improve and speed up the
diagnostic process and direct further investigative studies aimed at
arriving at the correct final diagnosis (Table 1):
- Referred pain from the cranium, chest, or abdomen. Each
disorder has individualized symptomatology and should be
differentiated by appropriate symptoms and signs. A high index of
suspicion is required. For example, a 66-year-old diabetic smoker who
complains of interscapular back pain with sudden onset should be
cleared for a cardiac or vascular event before proceeding to an
orthopedic workup.
- Pain with signs of infection. Fever, chills, hyperhidrosis,
leukocytosis, and increased acute phase reactants (CRP, ESR, ferritin)
should all point to an infectious etiology. The clinical picture can
be less clear in chronic or partially treated infections. Further
investigation involves computerized tomographic and/or MRI studies,
cultures, antibody levels (brucellosis, syphilis) and tissue diagnosis
when indicated.
- Pain with signs of nerve root compression. This category
includes any process that compresses the nerve root and causes pain
that is referred to the extremity with relevant segmental sensory,
motor and reflex abnormalities. It can be investigated by CT or MRI
scanning.
- Pain with signs of cord or cauda compression. This category
includes sensory level, paraplegia or paraparesis and signs of
myelopathy. It always requires imaging, preferably gadolinium-enhanced
MRI. Tissue diagnosis of any existing tumors is required.
- Mechanical pain. This refers to pain that depends upon movement
and effort and is relieved by rest and recumbence. A precise diagnosis
can be usually be achieved by careful history taking, physical
examination, and plain films. A CT scan may sometimes be needed to
improve detail.
- Rheumatic pain. This refers to pain that is not relieved by
rest and even increases at night, with prolonged morning stiffness,
good response to NSAIDs, and accompanied by pain or inflammation of
other joints. Diagnosis is by fulfilling the diagnostic criteria for
each disorder. Plain films of the hands can often differentiate
between various rheumatologic disorders, such as RA, osteoarthrosis,
and gout arthropathy.
- Pain with other characteristics, with or without local
tenderness. A precise diagnosis of the source of this pain can be
achieved by careful history taking and physical examination, and plain
films. A CT scan may sometimes be needed to improve detail. Specific
studies for metabolic/endocrine disorders may also be needed.