Neck Pain

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There are many causes of neck pain but fortunately very few of these are “serious”.
The first task is to ensure that a pain in the neck is not due to one of these:

• Underlying disease
• Cancer
• Infection
• Trauma / Injury
• Significant nerve damage.

Mechanical Neck Pain
It is probably the most common neck pain condition.
It is the term given to pain that is thought to arise from the structures at the back of the spine.
It may be felt only in the neck or may radiate into the arms, shoulder, or up into the head causing headaches. It may also radiate down the spine particularly around the shoulder blades. The most common targets for treatment are the muscles and the facet joints.

Nerve Root Compression
The nerve root is the term given to the nerve as it emerges from the bony spine. This can be the result of either a change in the intervertebral disc or of an overgrown of bone or ligaments. Either individual nerves can be affected or a number of them together.
Mere compression of the nerves does not always cause pain. Often some form of inflammation must occur.
Pain resulting from nerve root problems is not usually felt in the neck. Instead it is felt down in the arms. Where the pain is felt in the arms can give a clue as to which level of the cervical spine is involved and hence guide treatment.

Disc Problems.
As we get older the centre of the discs tend to lose water and become stiffer. This can begin as teenagers. With time the disc may bulge out and compress the nerves. Sometimes it may tear and release part of its contents that may irritate the nerve roots directly.
Disc problems often respond well to epidurals or nerve root blocks.

Spinal Stenosis
This is a narrowing that is the result of an overgrowth of bone. An example can be seen on the left.

Central Stenosis
Leads to a feeling of heavy arms.

Lateral Recess Stenosis
This tends to affect individual nerves and is usually self-limiting

Low Back (Lumbar) Pain

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There are many causes of back pain but fortunately very few of these are “serious”.
The first task is to ensure that a pain in the back is not due to one of these:

• Underlying disease
• Cancer
• Infection
• Trauma / Injury
• Significant nerve damage.

Mechanical Back Pain
It is probably the most common back pain condition.
It is the term given to pain that is thought to arise from the structures at the back of the spine.
It may be felt only in the back or may radiate into the buttocks, groin or legs; however it is rarely felt below the knees.
Mechanical back pain may occur in conjunction with any other cause of pain.
The most common targets for treatment are the muscles and the facet joints.

Nerve Root Compression
The nerve root is the term given to the nerve as it emerges from the bony spine. This can be the result of either a change in the intervertebral disc or of an overgrown of bone or ligaments. Either individual nerves can be affected or a number of them together.
Mere compression of the nerves does not always cause pain. Often some form of inflammation must occur.
Pain resulting from nerve root problems is not usually felt in the back. Instead it is felt down in the legs. Where the pain is felt in the legs can give a clue as to which level of the spine is involved and hence guide treatment.

Disc Problems.
As we get older the centre of the discs tend to lose water and become stiffer. This can begin as teenagers. With time the disc may bulge out and compress the nerves. Sometimes it may tear and release part of its contents that may irritate the nerve roots directly.
Disc problems often respond well to epidurals or nerve root blocks.

Spinal Stenosis
This is a narrowing that is the result of an overgrowth of bone.

Central Stenosis
Leads to a feeling of heavy legs. Walking up hill may be easier than down. A more diffuse feeling of pain.

Lateral Recess Stenosis
This tends to affect individual nerves and is usually self-limiting

Cauda Equina Syndrome
This is bad. It occurs when there is a large disc bulge that affects many of the nerves. There is a loss of bladder and bowel sphincter control. It is a surgical emergency.

Nerve Root Pain

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What is Nerve Root Pain?
Nerve root Pain is the name given to any sort of pain that is caused by irritation or compression of a nerve as it leaves the spine. Doctors often call it radicular pain although each of these terms is similar. If the pain is in the leg it is usually caused by irritation of the Sciatic Nerve – Sciatica. If the pain is in the arm it is called Brachalgia
The sciatic nerve is the longest nerve in your body. It runs from the back of your pelvis, through your buttocks, and all the way down both legs, ending at your feet.
Anything that compresses or irritates the sciatic nerve can cause a pain that radiates out from your lower back, and travels down your leg to your calf. Sciatic pain can range from being mild to being very painful.
Many people confuse general back pain with sciatica. The difference between sciatica and general back pain is that the pain of sciatica is not just limited to your back, but also stretches down your buttocks and into your legs.
If you have sciatica, you may have some numbness or muscle weakness in your legs and feet. Some people also experience a tingling sensation (‘pins and needles’) in their feet.
There are seven nerves leaving your neck and supplying your arms. Each of these may become trapped or irritated causing Brachalgia. The muscle wasting and pins and needles is usually felt in the shoulder, arm and hand.
The treatment of nerve root pain depends on how long it has lasted for:

• Acute nerve root pain: lasts up to six weeks.
• Chronic nerve root pain: lasts longer than six weeks.

Most cases of acute sciatica will settle without the need for treatment. Using a combination of over-the-counter (OTC) painkillers, exercise and hot or cold packs can often help to relieve the symptoms of nerve root pain.
In the case of chronic nerve root pain, you may require some structured physical exercise under the supervision of a physiotherapist. Injection therapies are often used and, in very rare cases, surgery may be required to control the symptoms.

What can cause nerve root pain?
In many cases of sciatica there is no single obvious cause. It is thought that general ‘wear and tear’ on the body may cause it. This is why the condition is more common in people who are over 40 years of age or those who have occupations that involve a lot of physical activity. One rare cause, cauda equina syndrome is extremely serious and you will often be asked questions relating to your bladder and bowel function, as doctors tend to want to exclude the most serious problems first.

Cauda equine syndrome
Cauda equine syndrome is a very rare and serious condition that can cause sciatica. However, unlike other causes, cauda equine syndrome can permanently damage the nervous system and, if it is left untreated, will lead to paralysis.
If you are experiencing sciatica, one of the warning signs of cauda equine syndrome is that you may suddenly and inexplicably lose control of your bladder or bowels.
If you have sciatica and experience a sudden loss of bladder or bowel control you should call 999 to seek immediate medical assistance.
Some other potential causes of sciatica are outlined below.

• Herniated disc - A herniated (or slipped) disc is the most common identified cause of nerve root pain. Your spine is made up of vertebrae, discs, and nerves. Vertebrae are the ridge-shaped sections of bone that make up the structure of your spine, and protect the nerves. The vertebrae are supported and cushioned by discs of cartilage. Cartilage is a type of tissue that is tough and flexible. As a person gets older the discs start to become harder, tougher and more brittle. Repeated strain on the back means that there is a chance that the hardened discs may split or rupture. If a rupture occurs some of the soft core of tissue inside the disc can press against the nerve, causing pain.
• Spinal stenosis - Spinal stenosis is caused by a narrowing of the spinal cord – the long tube inside the spine, which contains the nerves. As you get older, the spinal cord can narrow and a nerve may be compressed, leading to pain.
• Spondylolisthesis - Spondylolisthesis is a condition where the discs degenerate to such an extent that they are no longer able to properly support the vertebrae. This may lead to a vertebra slipping forward over the one below it. If this occurs in the lower back, the slipped vertebra can compress the sciatic nerve, causing sciatic pain. It is less common in the neck. Occasionally, nerve root pain may be caused by infection, injury or a growth within the spine.

Diagnosing Nerve Root Pain
If the symptoms of sciatica are mild and do not last longer than six weeks, a medical diagnosis is probably not required. This is because mild, short-term symptoms are not normally a cause for concern and will resolve without treatment.
If your symptoms are severe or the condition persists for more than six weeks. there is a small chance that they may be caused by a more serious condition.
Red flags
Your doctor or therapist can find out a lot about your problem by asking you questions about it. These questions can detect warning signs that your symptoms are caused by a serious condition, such as an infection of the spine or cancer. These warning signs are referred to as ‘red flags’.

Red flags include:

• You are over 50 years of age and have never had any previous back pain,
• You are under 20 years of age and have never had any previous back pain,
• You have a history of cancer,
• You have symptoms of fever, chills or unexplained weight loss,
• You have had a recent bacterial infection, such as a urinary tract infection,
• You inject illegal drugs (a leading risk factor for spinal infections), or
• You have a condition that suppresses your immune system, such as HIV.
• If you have one or more red flags your GP will probably recommend that you have a blood test in order to rule out conditions such as an infection. They may also recommend that you have an X-ray or an MRI scan. MRI scans use strong radio and magnetic waves to build up a detailed picture of the inside of your body.

Treatment

Acute Nerve Root Pain
Most cases of acute nerve root pain can be treated by using some self-help techniques. These are outlined below. Painkillers Over-the-counter (OTC) painkillers are usually effective in relieving symptoms of pain. The type of painkiller known as nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, is thought to work best. Ibuprofen is usually recommended rather than aspirin because there is less chance of adverse side effects. Children who are under the age of 16 should not take aspirin.
NSAIDs may not be suitable if you have asthma, high blood pressure, liver disease, heart disease or a history of stomach and digestive disorders. In these circumstances, paracetamol would probably be a more suitable painkiller for you.
If your sciatica symptoms are severe your GP may prescribe a mild opiate-based painkiller, such as codeine.
If your symptoms are very severe, your GP may prescribe a muscle relaxant, such as diazepam. Diazepam has the potential to be habit-forming, so your GP will not usually prescribe more than a seven-day course of the medication.

Exercise
If you have pain it is important for you to remain as physically active as possible. While bed rest may provide some temporary pain relief, prolonged bed rest will actually make your symptoms worse. Recommended exercises include walking and gentle stretching exercises.
If you have had to take time off work due nerve root pain, you should aim to return to work as soon as possible. While you will not feel any immediate benefit, research has shown that people who continue to work during an episode of sciatica recover quicker than those who stay at home.
Compression packs Many people find that using either hot or cold compression packs helps to reduce pain. You can make you own cold compression pack by wrapping a package of frozen food in a towel. Hot compression packs are usually available from larger pharmacies. You may find it helpful to alternate hot and cold.

Chronic Nerve Root Pain
Treating chronic sciatica will probably require a combination of self-help techniques and medical treatment. Treatment options are outlined below.
Painkillers The long-term use of NSAIDs as a method of controlling pain is not usually recommended because they can cause problems with your stomach and digestive system.
If you are required to take painkillers for a considerable length of time, the ones that are listed below may be used.
Paracetamol,
Codeine – paracetamol is often prescribed in combination with codeine,
Amitriptyline, and other antidepressants
Gabapentin., Pregabelin and other anticonvulsants
Amitriptyline is a medicine that was originally designed to treat depression, but subsequently doctors have found that it is also useful for treating nerve pain. You may experience some side effects when taking amitriptyline and other antidepressants.

They include:

• Drowsiness
• Dry mouth
• Blurred vision
• Constipation
• Difficulty urinating.

Gabapentin and preagabelin are medicines that were originally designed to prevent seizures in people with epilepsy but, like antidepressants, they have been found to be useful for treating nerve pain.
Possible side effects of gabapentin and pregabelin include weight gain, dizziness, tiredness, and loss of coordination.
If you wish to stop taking gabapentin / pregabelin or you no longer need to take it, your GP will arrange for your dose to be slowly reduced over the course of a week. This method will ensure that you do not experience any withdrawal symptoms.

Exercise and physical therapy

As with acute symptoms, if you have chronic nerve root pain you should try to remain as physically active as possible because this will reduce the severity of your symptoms. It is also recommended that you continue to work or return to work as soon as possible.
Regular exercise will help to strengthen the muscles that support your spine. Exercise also promotes the production of endorphins, which are natural pain killing chemicals. Your GP should be able to recommend a suitable exercise plan for you.
Your GP may also refer you to a physiotherapist or a chiropractor. A physiotherapist will be able to teach you a range of exercises that strengthen the muscles that support your back and improve the flexibility of your spine. They can also teach you how to improve your posture and reduce any future strain on your back.
A chiropractor can manipulate your spine in a way that can reduce any compression or pressure on your nerves, which will help to relieve your pain.

Cognitive behavioural therapy (CBT) 
Some studies have shown that a type of therapy called cognitive behavioral therapy (CBT) can help in the management of chronic pain.
CBT is based on the principle that the way we feel is partly dependent on the way we think about things. Research has shown that people who train themselves to react differently to their pain by using relaxation techniques and maintaining a positive attitude show a decrease in the levels of pain that they experience.
They are also more likely to remain active and take exercise, further reducing the severity of their symptoms.

Surgery
Surgery may be an option to treat cases of chronic pain symptoms when:
There is an identifiable cause, such as a ruptured hernia,
The symptoms have not responded to other forms of treatment, and
The symptoms are getting progressively worse.
The type of surgery that will be recommended for you will depend on the cause of your sciatica.

Some surgical options include:

• Discectomy – where the part of the herniated disc that is pressing on your nerve is removed,
• Fusion surgery – if a vertebra has slipped out of place, it may be possible to fuse it into place using metal rods, and
• Laminectomy – this procedure is used to treat spinal stenosis; the spinal cord is widened, reducing the pressure on your nerves

As with all surgical procedures, spinal surgery carries some risks. There is a one in 10 chance of infection developing after your surgery. This may require further surgery to clean out the infection, although some cases can be treated with antibiotics.
In the case of fusion surgery, there is a 1-2% chance of the vertebrae failing to fuse in place. If this occurs, further surgery will be required.
There is also a very low risk that your spinal cord will be damaged during surgery. This risk is estimated to be six in 1,000 (0.6%). This could result in problems ranging from some muscle weakness to total paralysis. Your bladder and bowel control may also be affected.
Before opting for spinal surgery, your surgeon will be able to discuss the relative risks and benefits with you.

In almost all cases, a trial of Injection therapy is used before surgery (see below). Injections are used to help in diagnosing the cause of sciatica as well as treating it. The majority of patients with chronic sciatica respond well to injections and can then use the self-management techniques outlined below to keep out of trouble.

Prevention of further episodes of spinal nerve root pain

Exercise
Exercises like walking or swimming strengthen the muscles that support your back without putting any strain on it or subjecting it to a sudden jolt.
Activities like yoga or pilates can help improve the flexibility and the strength of your back muscles. It is important that you carry out these activities under the guidance of a properly qualified instructor. There are also a number of simple exercises that are described below, which you can do in your own home to help prevent or relieve sciatica.

• Wall slides – stand with your back against a wall with your feet shoulder-width apart. Slide down into a crouch so your knees are bent to about 90 degrees. Count to five and then slide back up the wall. Repeat five times.
• Leg raises – lie flat on your back on the floor. Lift each heel in turn just of the floor while keeping your legs straight. Repeat five times.
• Bottom lifts – lie flat on your back on the floor. Bend your knees so your feet are flat on the floor. Then lift your bottom in the air by tightening your stomach muscles while keeping your back straight. Repeat five times.

At first you should do these exercises once or twice a day and then gradually increase to doing them six times a day, as your back allows.
These exercises are also useful for ‘warming up’ your back. Many people injure their back when doing everyday chores at home or work, such as lifting, gardening or using a vacuum cleaner. ‘Warming up’ your back before you start these chores can help prevent injury.

Posture
How you sit, stand and lie down is important and can have an important effect on your back. The tips outlined below should help you to maintain a good posture.

• Standing - You should stand upright, with your head facing forward and your back straight. Balance your weight evenly on both feet and keep your legs straight.
• Sitting - When sitting, you should be able sit upright with support in the small of your back. Your knees and hips should be level and your feet should be flat on the floor – use a footstool if necessary. Some people find it useful to use a small cushion or rolled-up towel to support the small of the back.
• Driving - As with sitting, make sure your lower back is properly supported. Correctly positioning your wing mirrors will prevent you from having to twist around. Foot controls should be squarely in front of your feet. If driving long distances, take regular breaks so you can stretch your legs.
• Sleeping - In the past, people with back pain were told to sleep on a firm mattress, but studies have shown that a medium-firm mattress is better. Your mattress should be firm enough to support your body while supporting the weight of your shoulders and buttocks, keeping your spine straight. If your mattress is too soft, place a firm board – ideally 2cm (three-quarters of an inch) thick – on top of the base of your bed and under the mattress. Support your head with a pillow, but make sure your neck isn’t forced up at a steep angle.
• Lifting and handling - One of the biggest causes of back injury, particularly at work, is people lifting or handling objects incorrectly. Learning and following the correct method for lifting and handling objects can help prevent brachalgia and sciatica.
  Think before you lift – can you manage the lift? Are there any handling aids you can use? Where is the load going?
  Start in a good position – your feet should be apart with one leg slightly forward to maintain balance. When lifting, let your legs take the strain – bend your back, knees and hips slightly but do not stoop or squat. Tighten your stomach muscles to pull your pelvis in. Don’t straighten your legs before lifting as you may strain your back on the way up.
  Keep the load close to your waist – keep the load as close to your body for as long as possible with the heaviest end nearest to you.
  Avoid twisting your back or leaning sideways – especially when your back is bent. Your shoulders should be level and facing in the same direction as your hips. Turning by moving your feet is better than lifting and twisting at the same time.
  Keep your head up – once you have the load secure look ahead, not down at the load.
  Know your limits – there is a big difference between what you can lift and what you can safely lift. If in doubt, get help.
  Push, do not pull – if you have to move a heavy object across the floor, it is better to push it rather than pull it.
  Distribute the weight evenly – if you are carrying shopping bags or luggage try to distribute the weight evenly on both sides of your body.

Further Reading
There is a lot of helpful information available on the internet if you would like to learn more. Unfortunately some websites are used to advertise treatments which are not proven or effective. Here are a selection of websites which contain accurate information based on scientific data and best practice.

• www.nhs.uk - This is the nhs website and is a good place to start
• www.backcare.org.uk - This is the website for the UK back care charity
• www.spine-health.com
• www.spine-universe.com - These two websites are American and have much more advertising than the UK sites do. They contain good exercise plans and general advice

Your doctor, as well as every other member of the team, is there to help you understand your condition and help you manage it as well as is possible. Please do ask us if you have any questions about anything that you have been told or may have misunderstood.