Potential cause
Red flags
Cancer
History of cancer
Unexplained weight loss
Progressive pain not responding to therapies
Nighttime pain, pain at rest
Vertebral infection
History of infection
Fever
IV drug use
Immunosuppression
Systemic symptoms such as fever with chills, high inflammatory markers
Fracture
History of trauma
Osteoporosis
Steroid use
Structural deformity
Midline spine tenderness
Myelopathy
Pain in the extremities
Weakness in the extremities
Sensory deficits and/or atrophy in the extremities
Hyperreflexia
Cauda equina syndrome
Bladder dysfunction
Bowel incontinence
Saddle anesthesia
Weakness of the lower limbs
Gait disturbance
Inflammatory (rheumatological) cause
Pain and stiffness worsening with rest
Morning stiffness (>30 min)
Altered inflammatory markers
Multiple joint involvement
26.2.3 Physical Exam
Physical examination of a patient who complains of NP should include evaluation of range of movement of the cervical spine (flexion, extension, rotation, and side bending), the cervical and thoracic segmental mobility test, the cranial cervical flexion test, and the neck flexor muscle endurance test. In patients with radicular symptoms, the physical examination should also include upper limb tension test, the Spurling test, the distraction test, and the Valsalva test [1]. In patients with radicular pain, an accurate examination helps to identify the involved nerve root: this means an accurate sensory testing, motor testing, and evaluation of deep tendon reflexes (see Table 26.2). Cervical facets can be examined by manual palpation of the spinal segments: pressure on the involved facet joints causes exacerbation of the usual symptoms. Evaluation also includes the palpation of neck muscles for tone, tenderness and contractures. Gait evaluation is important and may be abnormal if myelopathy is present. Validated scales and instruments, such as Neck Disability Index and Patient-Specific Functional Scale, allow to evaluate how pain can affect the activities of daily living (ADL). A surgeon or rheumatologist consultation may be appropriate in cases of neck pain associated with red flags [ 4 ].
Table 26.2
Cervical radicular referred pain—characteristics
Nerve root level | Sensory deficits/location of pain | Muscle weakness | Reflex |
|---|---|---|---|
C2 | Occipital, eyes | ||
C3 | Neck, trapezius | ||
C4 | Neck, trapezius | ||
C5 | Shoulder, lateral arm | Deltoid, biceps | Biceps |
C6 | Radial forearm, first and second digits | Biceps, wrist extension | Brachioradialis, biceps |
C7 | Third digit | Triceps, wrist flexion | Triceps |
C8 | Fourth and fifth digits, ulnar forearm | Finger flexors | |
T1 | Ulnar arm | Hand intrinsic muscles |
26.2.4 Imaging
When imaging is necessary, a plain radiograph is the first exam to be ordered in the elderly patient with NP, eventually associated to dynamic X-rays. Advanced imaging, such as CT, MRI, and bone scan, can be considered in case of NP, but not routinely, as there is a lack of evidence in the literature of the correlation between abnormal findings and patients’ symptomatology [4]. In patients with referred arm pain, an electromyographic study can be useful to distinguish peripheral nerve entrapment syndromes from cervical radiculopathy [11].
26.2.5 Pharmacological Therapy
In transient or short-duration NP, muscle relaxants are the only pharmacological therapy suggested by current evidence. NSAIDs can be considered in order to relieve pain in patients with long-duration NP. NSAIDs must be prescribed only for short periods due to their many side effects. There is no evidence for efficacy of acetaminophen/paracetamol [4].
26.2.6 Non-pharmacological Therapies
- 1.
- 2.
Pillows seem to be beneficial in reducing pain [12] and can be recommended as part of the NP treatment.
- 3.
Cognitive behavioral treatment might have a role in reducing pain and disability in the short term in patients affected by chronic NP, but its role is still to be demonstrated [13].
- 4.
Exercises are used in common practice in patients with NP. Strengthening, coordination, and endurance exercises are suggested in patients with NP and neck-related headache. Stretching exercises of the scalenes, trapezius, levator scapulae, and pectoralis minor and major can also be prescribed. Centralization exercises are not recommended [4]. Adverse effects after exercise are self-limiting and include headache; neck, shoulder, or thoracic pain; or symptom worsening [14].
- 5.
Physical therapy modalities: Low-level laser therapy (LLLT) is recommended for chronic NP, but not for acute patients [7]. Pulsed electromagnetic fields (PEMF), repetitive magnetic stimulation, and TENS might be effective in reducing pain (low-level evidence). Galvanic current, iontophoresis, electrical muscle stimulation, and static magnetic field do not seem to be useful in reducing neck pain [15].
- 6.
Massage can provide some relief from pain in chronic NP. It does not seem useful in acute NP [7].
- 7.
Cervical mobilization/manipulation seems to have a role in reducing both acute and chronic NP, especially when associated with exercises [4]. Maiers et al. suggested that in elderly population, spinal manipulative therapy associated with home exercises is more effective in reducing pain and disability than exercises alone in the short term [16]. Potential risks of mobilization/manipulation are local or radiating discomfort, headache, fatigue, or more rarely dizziness and nausea (in a minority of patients); however, these symptoms are usually transitory. There is only inconclusive evidence on the association between cervical spinal manipulative therapy and cervical artery dissection [17]. Contraindications to cervical mobilization are osteoporosis, inflammatory spondylopathy, vertebral metastases, or other weakening conditions of the spine.
- 8.
Thoracic mobilization/manipulation can reduce pain and disability [4].
- 9.
- 10.
26.3 Low Back Pain in the Elderly
26.3.1 Epidemiology
Prevalence of low back pain (LBP) in the elderly is approximately 25% [20]. Severe LBP seems to afflict 13% of older men and 20% of elderly women for at least 30 days every year [2].
LBP can be acute (<6 weeks), subacute (6–12 weeks), and chronic (>12 weeks). Ninety percent of patients affected by acute LBP recover within 6 weeks; however, LBP will persist more than 12 weeks in 2–7% of patients [21]. LBP can be classified in (a) mechanic or nonspecific LBP, (b) LBP associated with radicular pain, (c) LBP with an underlying serious pathology, and (d) LBP referring from a visceral disease [6, 9, 22, 27, 32].
26.3.2 Symptoms
26.3.3 Patient Evaluation
In limited cases, a serious disease could cause LBP. Therefore, patient evaluation must primarily aim at identifying signs, symptoms, and patient characteristics that will alert the physician (“red flags”). In particular, cancer can be suspected in a patient with LBP and a history of malignancy, nocturnal pain, symptoms at rest that do not respond to therapy, or if they are associated to weight loss. On the other hand, a history of recent trauma, osteoporosis, or recent use of steroids could be associated with a vertebral fracture, especially in the presence of an evident structural deformity of the spine. It is also important to look for symptoms of cauda equina and infection (Table 26.1).
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