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):
  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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.