Cervical Pain, Lumbar Pain, and Sciatalgia


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


Adapted from Chou et al. [6], Côté et al. [7], Dagenais et al. [8], and Van Tulder et al. [ 9 ]





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
 


Adapted from Frontera and Silver [1], Hoppenfeld [10], and Iyer [11]


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. 1.


    Education of the patient. For patients without red flags, clinicians must educate the patients about NP, reassuring them that it is usually a condition with a good prognosis, and should advise a quick return to normal activities [4, 7].

     

  2. 2.


    Pillows seem to be beneficial in reducing pain [12] and can be recommended as part of the NP treatment.

     

  3. 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. 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. 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. 6.


    Massage can provide some relief from pain in chronic NP. It does not seem useful in acute NP [7].

     

  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. 8.


    Thoracic mobilization/manipulation can reduce pain and disability [4].

     

  9. 9.


    Acupuncture seems to have a role in reducing NP [18]. Needling of myofascial trigger points, both dry needling and wet needling (using lidocaine or other local anesthetics), can be useful in relieving myofascial neck and shoulder pain; wet needling seems more effective [19].

     

  10. 10.


    Cervical collars [7], heat [7], and cervical traction are not recommended as they do not seem to provide any benefit.

     



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


LBP is usually defined as pain in the lower back, between the costal margin and the inferior gluteal folds [21], or the thighs; it can radiate to the legs with a radicular distribution, associated or not to sensory and motor symptoms (sciatica) [6].


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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Mar 29, 2020 | Posted by in GERIATRICS | Comments Off on Cervical Pain, Lumbar Pain, and Sciatalgia
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