musculoskeletal and connective tissue disorders
Evaluation of Neck and Back Pain
Treatment of Neck and Back Pain
Underlying disorders are treated. Acute musculoskeletal pain (with or without radiculopathy) is treated with Analgesics Lumbar stabilization and exercise Heat and cold Activity modification and rest (up to 48 hours) as needed Reassurance In patients with acute nonspecific (nonradicular) neck or low back pain, treatment can be started without extensive evaluation to identify a specific etiology. Treat patients with nonspecific, nonradicular back pain who have no red flag findings symptomatically, without first requiring testing. or nonsteroidal anti-inflammatory drugs (NSAIDs) are the initial choice of analgesics. Rarely, Opioid Analgesics may be necessary, using appropriate precautions, for severe acute pain. Adequate analgesia is important immediately after acute injury to help limit the cycle of pain and spasm. Evidence of benefit for chronic use is weak or absent, so duration of opioid use should be limited. When acute pain decreases enough that motion is possible, a cervical or lumbar stabilization program is begun under the supervision of a physical therapist. This program should be started as soon as practical and includes restoration of motion, exercises that strengthen paraspinal muscles, and instruction in work posture; the aim is to strengthen the supporting structures of the back and reduce the likelihood of the condition becoming chronic or recurrent. In low back pain, "core" (abdominal and low back) muscle strengthening is important and often begins with a progression from working on a table in a supine or prone position, to quadruped (on hands and knees), and finally to standing activities. Acute muscle spasms may also be relieved by cold or heat. Cold is usually preferred to heat during the first 2 days after an injury. Ice and cold packs should not be applied directly to the skin. They should be enclosed (eg, in plastic) and placed over a towel or cloth. The ice is removed after 20 min, then later reapplied for 20 minutes over a period of 60 to 90 minutes. This process can be repeated several times during the first 24 hours. Heat, using a heating pad, can be applied for the same periods of time. Because the skin on the back may be insensitive to heat, heating pads must be used cautiously to prevent burns. Patients are advised not to use a heating pad at bedtime to avoid prolonged exposure due to falling asleep with the pad still on their back. Diathermy may help reduce muscle spasm and pain after the acute stage. In patients with severe radicular symptoms and lower back pain, some clinicians recommend a course of oral corticosteroids or early referral to a specialist for epidural injection therapy. Facet joint corticosteroid injection is sometimes used for nonradicular pain. However, evidence supporting the use of systemic and epidural corticosteroid use is controversial. If epidural corticosteroid injection is planned, clinicians should obtain an MRI before injection so that the pathology can be identified, localized, and optimally treated. , benzodiazepines) are controversial. Benefits of these drugs should be weighed against their central nervous system (CNS) effects and other adverse effects, particularly in older patients, who may have more severe adverse effects. Muscle relaxants should be restricted to patients with visible and palpable muscle spasm and used for no more than 72 hours, except in some patients with central pain syndrome (eg, Fibromyalgia ) in whom nocturnal Although a brief initial period (eg, 1 to 2 days) of decreased activity is sometimes needed for comfort, prolonged bed rest, spinal traction, and corsets are not beneficial. Patients with cervical pain may benefit from a cervical collar and contour pillow until pain is relieved and they can participate in a stabilization program. Spinal manipulation may help relieve pain caused by muscle spasm or an acute neck or back injury; however, high-velocity manipulation may have risks for patients older than 55 (eg, vertebral artery injury with neck manipulation) and those with severe disk disorders, cervical Osteoarthritis (OA) , Clinicians should reassure patients with acute nonspecific musculoskeletal back pain that the prognosis is good and that activity and exercise are safe even when they cause some discomfort. Clinicians should be thorough, kind, firm, and nonjudgmental. If depression persists for several months or secondary gain is suspected, psychologic evaluation should be considered. 