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Cervical and Lumbar painNeck pain and back painNeurological manifestations and symptoms of systemic illnessHistory and physical examinationSymptoms resolve Symptoms persist Conservative managementAdditional evaluation by imaging & laboratory studies

NOYesHistory Pain : onset , character , location , radiation , aggravating and relieving factors and its intensity to differentiate between mechanical and inflammatory painMechanical PainInflammatory Pain at night activityMS < 30 min in morning restMS > 30 minCervical Myelopathy2ry to compression of the spinal cord due to degenerative disc disease.Symptoms of weakness of upper and lower limbs.Urinary or rectal incontinence .UMN signs on examination below the affected level and LMN signs at the same level.Some patients improve with conservative therapy , but in progressive myelopathy ; surgery is the choice. Cervical Myelopathy

Cervical SpondylosisNeck pain is diffuse and may radiate to shoulders , occiput or interscapular area. On examination : midline tenderness and pain on extension and lateral flexion.Plain x rays : intervertebral narrowing , osteophytes and facet joint sclerosis.TTT: patient education , NSAIDs , local injections and physiotherapy.

Cervical Spondylosis

Cervical StrainPain in middle or lower portions of the posterior aspect of the neck.On examination : local tenderness of the paraspinal muscles , ROM and loss of cervical lordosis.TTT: NSAIDs , muscle relaxants, local injections and neck exercises (ROM and strenghthening exercises).

NormalLoss of cervical curvatureCervical hyperextension injuries(whiplash)Acceleration-deceleration injury to the soft tissue structures of the neck.Stretched or torn paracervical muscles , injured intervertebral discs or damage to sympathetic ganglia.On physical examination : severe neck tenderness , ROM and paraspinal muscle contraction.TTT: NSAIDs , muscle relaxants, cervical collar.

Cervical RadiculopathyPain radiating from shoulder to forearm and hand .2ry to herniated cervical disc , osteophytes , inflammation of the involved root.Neck pain is minimal or absent.Physical examination (Spurling sign): extension , lateral flexion and compression of the cervical spine cause radicular pain.Neurologic examination : sensory abnormality , asymmetric reflexes, motor weakness corresponds to the affected root.Cervical Radiculopathy

Cervical Radiculopathy

Cervical Radiculopathy

234567Physical Examination of Neck PainInspection for active ROM , skin , masses.Palpation Tenderness of the midline structures (( intrinsic spinal disorders)) , but tenderness off the midline suggests soft tissue pathology). Passive ROMNeurological evaluationSpecial tests.Spurling maneuverExtending the neck and rotating the head to one side then compress and then to the other side .+ve result Radicular pain.Useful in confirming the presence of cervical radiculopathy.Spurling maneuver

Mechanical Back PainLumbar SpondylosisThe most commonly identified cause of LBP.Facet syndrome : pain may radiate into posterior thigh on bending ipsilateral to the involved facet joint.

Lumbar Spondylosis

Disc HerniationThe nucleus pulposus in a degenerated disc may prolapse and push out the weakened annulus fibrosus , usually posterolateraly.It results in nerve root impingement syndrome.95% occurs at L4/5 and L5/S1.Rarely a massive midline disc herniation compresses the cauda equina ending in cauda equina syndrome.Disc Herniation

SpondylolithesisIt is the anterior displacement of a vertebra on the one beneath it.

Degenerative spondylolithesis ; 2ry to degenerative changes in the disc and facet joints .

Isthmic spondylolithesis ; 2ry to developmental defect in the pars interarticularis of the vertebral arch.Spondylolithesis

Spondylolithesis

Spinal StenosisNarrowing of the spinal canal.Due to hypertrophied ligamentum flavum into posterior part of the canal, also herniated disc narrows the anterior part of the canal.Pseudoclaudication (neurogenic claudication): pain and discomfort together with parathesia and weakness in the buttocks , thighs and legs.by standing or walking and sitting or flexing forward.

Spinal Stenosis

Thickened ligamnetum flavumPhysical Examination of Back PainInspection for ROM , skin , masses and scoliosis .Palpation Tenderness of the midline structures (( intrinsic spinal disorders)) , but tenderness off the midline suggests soft tissue pathology). Passive ROMNeurological evaluationSpecial tests.Scoliosis

Straight Leg Raising test In patients with sciatica.It places tension on the sciatic nerve roots ( L4, 5 and S1,2 and 3).+ve when there is radicular pain when the leg is raised