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200 Ping Hong CHIN
and to a certain extent reasonable with the huge
amount of literature and studies available on low
back pain through Medline.
Epidemiology
Studies in Western countries have quoted the
prevalence of neck pain as approximately 80% of
the population. Yearly prevalence is 20–30% [10,
13, 33]. A study from the Chinese University of
Hong Kong reported a lifetime prevalence of 28%
and a yearly prevalence of 15% in men and 17%
in women; much lower than the figures from the
West [31].
For whiplash injuries, the incidence is about one
case per 1,000 per year in Western countries [4].
Some 12–18% of patients reported persistent
symptoms 6 months from injury, and 6–15% of
patients 1 year later [15, 39]. Costs in terms of
treatment, work loss and compensation are huge.
With such a high prevalence rate, neck pain
should not be casually related or ascribed to
an occupational or trauma cause without good
evidence; this can provide more complications
to already difficult medico-legal issues. Likewise,
casually putting a diagnosis (e.g. degeneration,
osteophytes, prolapsed disc) to such a common
clinical symptom as neck pain or back pain without
evidence would also encourage hypochondria in
the patient, leading to poor outcome in terms of
chronicity and disability.
Risk Factors
Studies have not revealed any evidence of work-
related mechanical factors contributing to neck
pain to justify the strategy of employing ergonomic
intervention to prevent occupational-related neck
pain [3, 30].
However, non-mechanical work-related factors,
like high quantitative job demands, working under
pressure and low co-worker support are proved to
be independent risk factors for back pain [2].
ere is no correlation found between neck pain
and the radiological finding of cervical disc disease
or other forms of minor radiological abnormalities,
such as bone spurs and disc protrusions without
neural compression [9, 25]. In the absence of a “red
flag” condition, there is little reason for radiological
investigation.
Looking for a Cause
A very small percentage of neck pain is caused by
tumours, inflammatory disease, infections and
other sinister local or systemic problems. History
and physical findings of weight loss, night sweat,
fevers, nocturnal rest pain or neurological deficit
would prompt the need to look further for the
cause, as with the “red flags” in the management of
low back pain.
Like low back pain, the definite cause of symptoms
for most neck pain is still unknown. Without
strong evidence to support various theories on the
pathophysiology of what we would call “nonspecific”
neck pain, clinicians and researchers turn their
efforts to locating “pain generators” in the neck as
well as in the back. Facet joints and intervertebral
discs are high on the list of biochemical and
neurophysiological studies in this respect [12].
Studies using diagnostic blocks have indicated that
cervical facet pain has a higher prevalence than that
of lumbar facet pain. Although for most of these
cases, radiological evidence of pathology is not
found on X-ray.
e localising of local “tender points” or “trigger
points” is however quite controversial. Studies
show that tender point counts are more related
to emotional and psychological conditions than
pathology or symptom severity [14, 49].
e range of motion should in general be recorded
during routine examination of neck pain patients.
However, general neck range limitation happens in
many patients with acute or chronic neck pain and
there is no evidence of its relationship to prognosis
or to indicating the cause of the pain.
Chiropractors or manual therapists tend to record
local segmental dysfunctions. However, the inter-
examiner reliability of these signs is questionable
[22].
In the absence of a clinical history suggestive of
“red flag” conditions and excluding cases following
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Neck Pain 201
significant trauma, there is rarely anything sinister
that can be shown by X-ray, computed tomography
(CT) scan or magnetic resonance imaging (MRI),
as pointed out by Bogduk of several studies [7].
Even with a history of trauma, the value of
radiological investigation is less useful in clinical
management than might be expected. Hoffmann
found that by excluding patients with no midline
cervical tenderness, no focal neurological deficit,
normal alertness, no intoxication and no painful
distracting injury, of 30,000 patients with blunt
trauma to the neck, only eight cases were missed out
of 818 true fractures by not reading their X-rays,
and only two of those eight cases were clinically
significant [24]. However, there is controversy as to
whether such misses are affordable in the practicing
environment. A history of trauma to the neck makes
the ordering of a set of X-rays a reasonable caution.
Ferrai and Russell have suggested that the problem
of this practice of X-ray screening is not one of
economics, but rather the wrongful attribution
on the part of patients of some special significance
to otherwise benign findings [20]. Care should be
taken to discuss this with patients before ordering
X-rays.
As mentioned above, the radiological finding of
cervical spondylosis is not related to prevalence or
severity of neck pain. However, many clinicians
still substitute a diagnosis of cervical spondylosis or
cervical disc disease for the aetiology of neck pain.
Besides offering nothing to clinical management,
such labelling of patients only deepens their
concern. Some patients even adopt a regressive
strategy “to prevent further harm” to their spine,
limiting activities and exercise, and seeking help
from multiple forms of alternative, passive medical
treatments for this wrong diagnosis for which
Western medicine does not offer a cure. Strong and
firm remarks should be made to patients against
this diagnosis should it be encountered.
ere is no justification to the ordering of a CT scan
without an X-ray finding of abnormality. Studies
have shown that MRI carried out in cases which
present solely with neck pain and no objective
neurological abnormality does not demonstrate
abnormalities consistent with or diagnostic of
the cause or source of pain; rather, MRI shows
abnormalities such as bulging discs and foraminal
stenosis, which are features common in ordinary
asymptomatic individuals [6, 45]. ese findings
can lead patients to over-react and clinicians to
over-treat.
Provocative testing, in terms of discography, is
as controversial for neck pain as it is for lumber
pain. e implication of a positive discography is
the incriminating of an intervertebral disc and the
indication for an invasive procedure like Intradiscal
Electrothermal Annuloplasty (IDET) in the lumbar
region or surgical fusion for both neck and lumbar
conditions. Without strong, valid evidence, great
care should be exercised always in enlisting patients
into discography (actually a procedure of disc
stimulation) over the neck in the first place.
Assessment of
Complications
Neck pain may not come only from the initial
pathology, which clinicians miss much of the time.
Neck pain can come from complications over
time, well after the initial pathology is healed or
become silent. Such complications include neck
stiffness, muscle atrophy or spasm, dysfunction of
deep muscles, kinaesthetic deficits, shoulder girdle
dysfunctions and so on.
Uhlig showed the transformation of muscles fibres
from Type I to Type II over neck flexors in patients
with neck pain, irrespective of aetiology [48]. is
affects the endurance and strength of neck muscles,
causing easy fatigue and discomfort for patients [21,
47]. Just as the multifidus and transversalis muscles
are considered to have an intrinsic stabilising effect
in low back pain, deep neck muscles, including
the longus colli, longus capitus and rectus capitis
posterior major and minor muscles, may serve the
same function and are found to be dysfunctional
in patients with neck pain [18, 19]. Concomitant
increase of activity in the superficial neck muscles
are found as a substitution strategy for the loss of
the deep muscles’ stabilising function, especially in
cases with higher neck disability indices [43]. With
such dysfunction in the co-ordination of deep and
superficial muscles, pain resulting from minor
injuries during ordinary movement can occur
independently of the original cause.
Researchers have also found postural differences
in patients with chronic neck pain, in terms of
greater head-neck angles, that is a more head-
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202 Ping Hong CHIN
forward posture, after working for some time [44].
Sustaining such a posture may lead to abnormal
biomechanical stress contributing to neck
discomfort, fatigue and pain.
For those with whiplash-associated disorders, sensory
hypersensitivity and deterioration of proprioceptive
sense in terms of increased joint position errors are
also found. ey are much worse and persistent in
patients with higher neck disability indices or in
other words, symptomatically more severe cases.
ese functional disturbances can contribute
significantly to the discomfort and disability of
such patients, in symptoms like dizziness or other
vague complaints [42].
Treatment Options
Pain is a subjective sensation. Most clinicians still
use simple tools like the visual analogue scale to
assess the intensity of a sensation which only the
patient himself can truly describe.
With such subjectivity, it is very difficult to
objectively assess, even in well-designed prospective
studies, the efficacy of various treatments against
pain. One way to try to objectively assess the
disability for patients and measure outcome is the
Neck Disability Index developed by Howard Vernon
[46]. is index has become a standard instrument
for measuring self-rated disability due to neck pain.
is is a useful tool for the preliminary assessment
of the patient, so that progress can be objectively
assessed together with the patient.
Over the years, more and more treatment options
have been discredited rather than supported by
evidence-based medicine. However, evidence-based
suggestions are still better than conjectures.
Except for “red flag” cases, the pathophysiology of
neck pain still eludes us. For this, we remain like
quantum physicists, still very hopeful but short
of establishing a universal theory. We still lack the
ability to get right to the cause of pain. Treatment
options such as trigger point injection, local
massaging and an arsenal of physical modalities
are available, if one thinks that the cause lies in
the soft tissues. Transcutaneous electrical nerve
stimulation (TENS) might be advised for believers
of the dorsal horn concept of pain. McKency
exercises can be prescribed for “derangement of
the disc”. Manipulation of the facets may serve
for “facet joint syndromes”. In acupuncture use,
the concept is with the meridians. Without a truly
proven pathophysiology, we are treating only by
conjecture, or trial and error.
From the orthopaedic surgeon’s standpoint,
evidence is yet to be provided in the literature for
the surgical treatment of patients with chronic neck
pain. Consequently, the discussion that follows
focuses on non-surgical options of treatment.
For clinicians who choose to target pain generators,
the best studied are those around the facet joints
and the discs. Systematic reviews of injections [5]
and radiofrequency denervation [32] were unable
to document the efficacy of such treatments for
the neck or back. Surgical fusion can theoretically
eliminate all intradiscal pain generators; however,
no controlled studies provide good evidence to the
efficacy of this either.
For acute neck pain, the priority should be to identify
“red flags” and locate possible injuries. Without the
location of a significant pathology, as with most
whiplash-associated disorders, the usual option is
to provide a course of multimodal symptomatic
treatment, usually to include an analgesic and
physiotherapy. is approach can be regarded as
an effort to provide, as much as possible, the best
environment for the body to heal itself by nature.
Active treatment should be limited to actively
preventing complications. e complications
to be most feared are the deconditioning of the
musculoskeletal structure involved and the sinking
of the patient into his own sick role.
Whiplash-associated disorder is the most studied
among acute neck pain disorders. e most quoted
study is that from the Quebec Task Force on
Whiplash-Associated Disorder [41]. McKinney also
reported that on a 2-year follow-up, those prescribed
home exercise showed the highest percentage of full
recovery compared with all other treatment options
[34]. is review found that active exercise therapy
is superior to reliance on passive modalities. Peeters
et al. provided another recent review which serves to
emphasise active treatment over passive modalities
[40]. Borchgrevink et al. described an interesting
study [8]. Patients attending emergency units for
whiplash injury were divided at random into two
groups. Both groups were prescribed non-steroidal
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Neck Pain 203
anti-inflammatory drug for 5 days. One group of
patients was given 14 days’ sick leave and a neck
collar each. e other group received nothing but
the advice to act as normally as possible and not
to take sick leave. e study showed that the “act
normal” group, which was also the “no collar”
group, had much better results when reviewed at
6 months.
e consensus is clear: acting as normally as
possible and being prescribed home exercises
are the two treatment options that are given the
most documented merit. Both serve to keep the
musculoskeletal structures in good shape and to
prevent the adoption of a hypochondriacal attitude.
In chronic neck pain, it is doubtful whether the
true cause for most neck pain presented to us is
ever clear. e condition the patient presents,
however, may be a picture of musculoskeletal and
psychological complications of the initial pathology
with time. e practical approach is therefore to
treat the patient’s present pain problem, as well
as to decondition the patient both physically and
psychologically.
e musculoskeletal complications in chronic neck
pain have been dealt with in the previous section.
Not all chronic neck pain exhibits all the described
complications, and thus not all chronic neck pain is
the same. A thorough physical examination should
be performed to assess the physical condition of
the musculoskeletal neck per se, and each problem
treated accordingly.
Patients with neck pain sometimes present with
impairment of muscle function in the deep
stabilising muscles of the neck [37] and the girdle
muscles [36]. Abnormal tilting of the scapulae
is often found on physical examination. e
superficial neck flexors, on the other hand, are
quite often hyperactive with increased fatigability
of these muscles. Surface electromyogram studies
have also shown abnormality in the activation of
cervical muscles compared with those of persons
without neck pain [18]. ese problems happen
early after injury [43] and do not automatically
resolve even if the pain decreases [27, 43].
Traditionally, general strength and endurance
exercise programmes for the neck are prescribed.
Meta-analyses have yet to conclude strong evidence
of good outcome [1, 29, 38].
Jull proposed tackling the co-ordination problem
between deep and superficial cervical muscles at
an early phase. e patient was taught to perform
craniocervical flexion exercises, holding the
head position and meanwhile trying to relax the
superficial flexor muscles. A feedback mechanism
in terms of a bladder gauge put over the back
of the neck was used to keep the pressure level
without excessive use of the superficial muscles.
is is a similar approach as that used for the
lumbar spine for chronic back pain patients.
Patients are also trained to reposition their own
scapulae in a better functional position. Once re-
education of deep and superficial muscles activity
and girdle posture is achieved, the strength and
endurance requirements of the neck in general
can be addressed [26].
Concomitant sensory dysfunction in terms of
positional sense and thus dysfunction in balance
are found in some patients, especially in cases of
whiplash-associated disorders. Balance retraining
can be carried out using a wobble board, Swiss ball,
eye fixation exercises and so on.
For local stiffness and tenderness over facet joints,
and a decrease in the range of neck movement in
general, a course of manual therapy to mobilise the
respective facet joints is reasonable. Several studies
show evidence of efficacy for manual therapy on
the neck [11, 17, 23]. Possible postural problems,
such as a projecting chin or forward drifting of
head position, should also be corrected. Stretching
exercises to be done at home to mobilise joints and
relax muscles are also useful.
A recent Cochrane review indicated that a
multimodal programme incorporating mobilisation,
manipulation and eye fixation exercises provides
evidence of better results for chronic neck pain
patients [28].
An arsenal of physical modalities, without any good
evidence-based support and much overshadowed
by more active forms of treatment, is available to
clinicians. Despite being short on evidence, when
they are singled out in controlled randomised trials,
they have been shown to be helpful in practice as
an adjunct to active treatment. However, passive
treatment can lead to dependency, passivity,
inactivity and other sick-role behaviour, and
should always be provided together with active
treatment.
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204 Ping Hong CHIN
In general, clinicians lack training in assessing
and treating the psychological factors involved in
patients with chronic neck and back pain. However,
it is important to stress the need for expertise in this
respect, a need that should not be taken lightly. We
do not have the privilege of having Waddell signs for
patients with neck pain and we should not extrapolate
findings from non-organic problems of back pain
to neck conditions without using considerable
discretion. e help of a clinical psychologist is
valuable in this respect (see Chapter 37).
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Solving Approach
As we are still unable to discover the cause, or
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conditions, a reasonable and practical approach is
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concomitant problems they present with, and to
solve them one by one using a multimodal problem
solving, individualised treatment programme.
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Neck Pain 205
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Introduction
Back pain is a common and important health issue. It is an
individual report of a personal symptom, often with some
degree of disability that can be quite variable. e causes
can range from a minor injury in our usual life experience
that is often responsive to self-treatment to part of a serious
spinal disease that requires careful medical attention. ere
are multiple modulating factors which may affect the clinical
presentation of different patients, even with the same pathology
[110].
e concept of back pain has changed in recent decades and
it is now considered more as an illness syndrome rather than
having a distinct disease pathology. Discussions range widely
on this topic, from pathology and classification to clinical
presentation and treatment. is chapter focuses on the
different pathologies causing back pain and the treatment of
back pain with a well-defined cause. Non-specific low back
pain and its different types of management are also discussed.
Denition
Low back pain can be defined as pain at the midline between
the costal margin and the inferior gluteal fold, and should be
differentiated from loin, groin and gluteal pain [20, 49, 69].
Generally, pain lasting for less than 6 weeks is classified as
acute pain. Subacute pain is defined as pain of between 6 and
12 weeks’ duration. Chronic pain is defined as pain that lasts
for more than 12 weeks. Despite this being a well-accepted
classification, it is oversimplified and can sometimes be
misleading, resulting in pain being defined simply according
to its duration [20, 97, 110].
Back Pain
13
Hau Yan KWOK, Kenneth M.C. CHEUNG
INTRODUCTION
DEFINITION
EPIDEMIOLOGY
AETIOLOGY AND PATHOLOGY
SPECIFIC LOW BACK PAIN
Degenerative disc disease
Prolapsed interv
ertebr
al disc
Spondylolisthesis
Spinal stenosis
Osteoporotic vertebral fracture
Failed back surgery syndrome
Facet joint dysfunction
Other diagnoses
NON-SPECIFIC LOW BACK PAIN
CLINIC
AL PRESENT
ATION
Nerve compression
Irritation at the disc
Instability
Problem in alignment
MANAGEMENT
Clinical history
Ph
ysical examination
In
vestigation
TREATMENT OPTIONS
CONCLUSION
REFERENCES
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208 Hau Yan KWOK, Kenneth M.C. CHEUNG
Epidemiology
e lifetime prevalence of back pain ranges from
40–60% in the general population, and the point
prevalence ranges from 15–30%. e data are
comparable and similar within different large and
representative population surveys, and are similar
across different cultures and ethnic origins [69].
Despite the similarity, there is a large variability
within studies; different methodologies and
definition of symptoms make estimation of the
true prevalence difficult. e incidence within age
groups is found to be similar [69].
Most back pain is self-limiting. Five to 10% of
patients develop recurrent symptoms [67, 70],
although some recent studies have shown that the
recurrence rate may actually be higher [43, 76, 111].
Other chronic musculoskeletal pain symptoms are
also closely related. A local cross-sectional survey
by telephone interview of a random adult sample
revealed a 10.8% prevalence of chronic pain, with
joint pain, followed by back pain and headache the
commonest site of occurrence [72].
Aetiology and Pathology
Numerous pain receptors are located in the lumbar
spine region. Most are concentrated at the annulus
fibrosis and facet joint, supplied by the dorsal
spinal nerve root. e cauda equina and the spinal
nerve roots at the segmental spinal level are in close
proximity, subject to irritation and may produce
neuropathic pain.
Back pain can be broadly differentiated into
localised back pain and lower limb pain. Localised
back pain in the lower back region is believed to
be a result of local pathology. It may be caused by
problems of alignment, instability during motion,
or irritation of the nervous structure. Leg pain may
be due to referred pain, muscle pain due to spasm,
or neuropathic pain at the sciatic nerve distribution.
is last pain condition is often referred to as
sciatica.
e understanding of back pain remains limited.
Conditions with a clearly labelled clinical diagnosis,
and described as specific low back pain, constitute
only 15% of all back pain problems [24]. In
specific low back pain, some 50% of cases are due
to prolapsed intervertebral disc. Other diagnoses
include spondylolisthesis, spinal stenosis, failed
back surgery syndrome, primary or secondary
tumour, fracture, inflammatory disease, etc. Often
an exact pathoanatomical association cannot be
identified and the causes may be multifactorial,
including psychological and social factors. If no
distinct pathology can be identified, the pain is
categorised as non-specific low back pain.
Specic Low Back Pain
Degenerative disc disease
e intervertebral disc is an avascular structure and
attains its nutrition from the surrounding vertebral
endplate. It serves to bear the load between the
vertebral bodies. e nucleus pulposus is the
centrally located hydrophilic structure composed
mainly of a type II collagen network and a
gelatinous proteoglycan core which imbibes water.
e annulus fibrosus is the outer layer of the disc,
with overlapping lamellae of type I collagen. It
withstands most of the tensile, torsional and radial
stress across the intervertebral bodies. e vertebral
endplate surrounds the disc and provides nutrition
by diffusion. Degenerative process will lead to
decrease in water content and decrease in disc space
[14]. e collagen content at the annulus changes,
with fissuring and radial tear, and causes the
disc to budge out. Extrusion of the disc material
may occur at the annulus defect. With these
pathological changes, the disc can become a source
of pain. Preceding trauma before changes occur is
referred to as internal disc disruption. e annulus
is a heavily innervated structure and the escape of
protein from the annulus tear will act as a noxious
stimulus to the nearby nociceptors.
Sometimes the source of the back pain cannot be
localised, even with specific anatomical findings,
as some of the findings may not cause physical
symptom in some patients. It is also known that
painful symptoms can be modified by psychological
and social variables.
Prolapsed intervertebral disc
is is a well-recognised form of back and leg pain
due to radiculopathy. When the nucleus pulposus
from the intervertebral disc escapes from its normal
anatomical confines, it can irritate the adjacent
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Back Pain 209
nerve root, causing typical radiculopathy pain.
Besides direct mechanical compression, the nucleus
pulposus itself is also a biologically active tissue
and may induce significant inflammation, causing
nerve root symptoms. e type of herniation can
be defined by its relationship with the annulus and
the posterior longitudinal ligament. A contained
bulging disc occurs when the nucleus pulposus still
has not pushed through the annulus. An extruded
disc is when the nucleus has pushed through the
annulus, but is still connected to the remaining
nucleus. A sequestrated disc is when the nucleus
has been detached from the inside portion and has
the potential to migrate from the level of the disc
(Fig. 13.01). Typically, the nerve root of the lower
segment close to the distal pedicle is affected (e.g. L5
root in a L4/5 prolapse). e nerve root of the upper
segment may be involved if there is a sequestrated
free fragment or a far lateral disc protrusion.
Spondylolisthesis
Spondylolisthesis refers to a condition where there is
a displacement of one lumbar vertebra over another
or the sacrum. Pathologically, it is classified as
congenital, isthmic, adult degenerative, traumatic
and postsurgical. e isthmic type and the adult
degenerative type are the commoner types found
in the adult population [114]. Spondylolisthesis
can be graded according to the percentage of slip
as measured by the length between the posterior
margin of the inferior end plate over the superior
end plate of the distal segment [65]. Insufficiency
of the pars interarticularis is found in the isthmic
type of spondylolisthesis.
In the degenerative type of spondylolisthesis, the
slip is due to the instability between the vertebrae.
e instability is the result of a degenerative
process, including the loss of support from
the intervertebral disc, and repeated stress and
remodelling at the facet joint. It is commoner in
females, usually presents at around or after the age
of 60 years, and usually between the fourth and
the fifth lumbar vertebrae because of the shearing
forces at that level. Patients commonly present
with mechanical back pain due to instability, or
there may be symptoms of radiculopathy and
Figure 13.01 Anatomical changes in prolapsed intervertebral disc.
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