Principles of assessing back and neck pain
People who present with back or neck pain should undergo a thorough history and physical examination to help identify:
- alerting features that may indicate a serious underlying pathology
- neurological symptoms or signs that may indicate radicular spine pain or myelopathy
- nonspecific causes of back and neck pain.
Nonspecific local musculoskeletal back or neck pain is usually constant in its location, dull or aching in character but may have sharp exacerbations. Often the pain is related to specific movements or postures rather than exertion.
Nonspecific low back pain is poorly localised and often influenced by posture and movement. It may be associated with nonradicular leg pain that is also poorly localised and dull or aching in character; this is described as somatic referred pain.
Physical examination may include:
- postural assessment for scoliosis, kyphosis, and visible muscle contraction or wasting
- assessment of the torso for skin rashes (eg herpes zoster shingles) or scars
- neck examination for restricted range of movement and local tenderness; this may indicate neck pain that is of local origin but does not provide a precise anatomical diagnosis
- back examination for restricted range of movement (rotation, flexion and extension), chest expansion and local tenderness; this may indicate back pain that is of local origin but does not provide a precise anatomical diagnosis
- neurological examination, including
- sensory examination over the chest wall to determine if there is altered sensation in a dermatomal distribution or if there is a sensory level
- lower limb examination for long-tract signs, specifically weakness, hyperreflexia or hyporeflexia, upgoing plantar responses or sensory loss
- abdominal and pelvic examination
- hip examination for range of movement and irritability.
The vast majority of people seen in primary care with back or neck pain have no neurological symptoms or signs, or alerting features of serious underlying pathology. Further investigation is usually not necessary in these people.
For detailed advice on assessing someone with musculoskeletal symptoms, see Clinical assessment of musculoskeletal symptoms in adults.