Acute and chronic cervical and lumbar pain
CONSULT TREATMENT PROTOCOL

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Non-specific cervical pain with no pathological correlate of injuries and diseases such as vertebral fracture, herniated vertebral disk, spondylodiscitis, spondylolisthesis, ankylosing spondylitis, primary and secondary bone tumors, bacterial and/or viral inflammations, etc. (henceforth referred to as non-specific cervical pain) is defined as persistent pain or severe discomfort in the neck for more than three months. In most cases the pain is caused by poor posture and/or mechanical and degenerative changes. The prevalence of chronic non-specific cervical pain was estimated to be approximately 50% in high school adolescents, and has substantially raised during the last decades because of the modern western lifestyle (including the excessive use of personal computers). The social and economic impact of non-specific cervical pain is substantial.

Non-specific lumbar pain with no pathological correlate of injuries and diseases such as vertebral fracture, herniated vertebral disk, spondylodiscitis, spondylolisthesis, ankylosing spondylitis, primary and secondary bone tumors, bacterial and/or viral inflammations, etc. (henceforth referred to as non-specific lumbar pain) is common and affects people of all ages. It is second only to the common cold as the most common affliction of mankind and is among the leading complaints bringing patients to physicians’ offices. Its reported point prevalence is as high as 33 percent, its one-year prevalence as high as 73 percent and its lifetime prevalence exceeds 70% in most industrialized countries, with an annual incidence of 15-20% in the United States. In physically active adults not seeking medical attention, the annual incidence of clinically significant non-specific lumbar pain with functional impairment is approximately 10-15%. An alarming increase in the prevalence of chronic non-specific lumbar pain has been observed in industrialized countries over the last years, affecting both men and women and across all ages and racial and ethnic groups. As in case of non-specific cervical pain the social and economic impact of non-specific lumbar pain is substantial. It is the most frequent cause of disability for people under age 45. Acute non-specific lumbar pain (lasting three to six weeks) usually resolves in several weeks, although recurrences are common and low-grade symptoms are often present years after an initial episode. Risk factors for the development of disabling chronic or persistent non-specific lumbar pain (variously defined as lasting more than three months or more than six months) include pre-existing psychological distress, disputed compensation issues, other types of chronic pain and job dissatisfaction. Diagnosis is based on clinical features. Diagnostic imaging should be considered to rule out other causes of lower back pain (particularly in chronic cases) or to establish the diagnosis of non-specific lumbar pain when in doubt.

The goals of management for patients with non-specific cervical and lumbar pain are to (i) decrease the pain, (ii) restore mobility, (iii) hasten recovery so the patient can resume normal daily activities as soon as possible, (iv) prevent development of a chronic recurrent condition, and (v) restore and preserve physical and financial independence and comfort. However, management for patients with non-specific cervical and lumbar pain is challenged by the following problems: (i) most back pain has no recognizable cause; (ii) an underlying systemic disease is rare; (iii) most episodes of back pain are unpreventable, and, most importantly, (iv) few if any treatments have been proven effective for non-specific cervical and lumbar pain. Among those treatments are limited bed rest, exercise, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol), muscle relaxants and opioids (if acetaminophen or NSAIDs do not relieve the pain), chirotherapy, physiotherapy and, ultimately, surgery (in cases of cauda equina syndrome, infections, tumors and fractures compressing the spinal cord, mechanical instability of the back, and, perhaps, intractable pain with a positive straight-leg-raising test and no response to conservative therapy). However, the analgesic effects of many treatments for non-specific cervical and lumbar pain are small and do not differ in populations with acute or chronic symptoms. Extracorporeal shock wave therapy is an alternative to conservative treatment and should be applied before considering surgery.

Radicular and pseudoradicular lower back pain are different types of pain that radiate distally at the legs. Radicular pain radiates below the knee and is thought to stem from disorders associated with nerve root compression which is often felt in distal dermatomes below the knee (projected pain). In contrast, pseudoradicular pain does not radiate below the knee and is thought to be associated with local proximal disorders that do not affect any nerves or nerve roots. These disorders include facet joint affection, piriformis syndrome and several other conditions. The associated pain is perceived in proximal dermatomes within the thigh (referred pain, head zones). In many cases of pseudoradicular lower back pain, it is impossible to find the underlying disease characterizing these cases as idiopathic. The distinction between radicular and pseudoradicular lower back pain is clinically relevant for several reasons: (i) radicular pain has always a neuropathic component because it always involves damage or irritation of peripheral nerves or nerve roots. In contrast, pseudoradicular pain may occur without damage or irritation of peripheral nerves or nerve roots and, thus, might be purely nociceptive. This distinction is very important when evaluating the results of neurophysiologic examinations. (ii) Radicular pain (neuropathic pain) is predominantly sensitive to antidepressants and anticonvulsants. In contrast, pseudoradicular pain (nociceptive pain) is predominantly sensitive to nonsteroidal anti-inflammatory drugs (NSAIDS). Diagnosis is based on the clinical features. Diagnostic imaging should be considered to rule out other causes of lower back pain or to establish the diagnosis of radicular or pseudoradicular lower back pain when in doubt. However, it should be noted that abnormalities found in radiological examinations in the lumbar spine poorly correlate with clinical symptoms. Extracorporeal shock wave therapy is a very effective alternative to conservative treatment in pseudoradicular lower back pain.