Neck, Chest, and Low Back Spine Pain
Neck (cervical), Chest (thoracic), Low back (Lumbar) spine pain
Back pain affects 85% of American at some time in their lives.
Cervical (neck), thoracic (chest), lumbar (low back) can all be caused from a herniated disc, degenerative disc disease or spinal stenosis. All three eventually end up pressing directly on nerves that come from the spine. The most common site of disease pathology in the neck is at L5 -L6, L6 -L7 and in the lumbar at L4 -L5, L5-S1, as they are the major functional and weightbearing levels. All can have pain from tumor, infection or fracture.However, frequently the nonsurgical or biomechanical causes of spine pain are not diagnosed as the answer is in the physical examination and not in a sophisticated test such as an MRI or CT scan.
A frequent cause of neck (cervical) pain is forward head carriage. Neck pain usually has a biomechanical component from the rest of the spine. If the mid thoracic spine does not move the head will be forced forward for every inch the head is in front of the shoulder is an additional 12.5 lb. load on the neck. Decreased range of motion of shoulders causes overuse of neck muscles as the body tries to compensate.Neck muscles are frequently overused if there is not complete range of motion of the shoulder. If the patient has a herniated disc or spinal stenosis selective nerve root block or epidural stenosis will be performed to treat the irritated nerve and then the underlying biomechanical problem that caused the neck pain will be corrected.Case Study – Neck PainThe patient was a 45 yr old highway construction laborer who used a “Jackhammer” regularly. 15 years prior to evaluation he had anterior cervical spinal surgery to decompress C6 – C7 with very good results. He was referred by his surgeon for C5-C6 selective nerve root block to evaluate if the cervical stenosis at C5-C6 was severe enough to warrant cervical spine stabilization. On physical examination the right shoulder would impinge at 165 degree abduction. This forced him to overuse his cervical muscles. Patient experienced significant improvement in neck pain once he had full range of motion of the shoulder. Repeat fusion surgery was postponed.
Chest (thoracic) spine pain may be caused by rotated ribs which will cause decreased movement of vertebrae where they attach. This is frequently seen in victims of MVA, shoulder sports injuries, breast cancer treatment, or open heart surgery for example.Case Study – Chest pain after open heart surgeryThe patient was evaluated in the clinic accompanied by his wife with a chief complaint of left chest wall and arm pain. Six months prior to evaluation he had open heart surgery, during which the sternum was split and the rib cage was retracted for visualization of the heart. When he developed the chest pain after surgery, a stress test and repeat cardiac catheterization were performed. No vascular blockage was found and the patient was directed to take acetaminophen for the pain. The patient complained he could not breathe, could not sleep, and lying on his back increased his pain. During severe bouts of pain he not only became short of breath, but also simultaneously had pain down the left arm. The patient was examined and x-rayed in the office; spine films showed significant advanced thoracic spondylosis (arthritis) as well as lumbar spondylosis. Most likely, the patient had had a true leg length discrepancy his entire life. Because of the arthritic condition of the spine, it was opted not to consider fitting the patient with a lift as this could increase his pain. The patient was treated conservatively with extensive myofascial release of the chest and arm and gentle mobilization of the ribcage. He had some paravertebral injections in the upper thoracic spine to modulate the hypersensitivity and trigger point injections in the pectoralis and shoulder girdle muscles. The patient is now pain free.
Low back pain
Low back (lumbar) pain can be caused by decreased movement in the sacroiliac joint, muscle imbalance causing vertebral rotation or pelvic obliquity.All levels of spinal pain will have a myofascial component. A herniated disc will lead to muscular spasm. Often after surgery it is this residual muscle spasm that goes untreated.Case Study – Low back painA male patient was referred to the clinic by his neurosurgeon for post-lumbar fusion pain. The patient’s radicular pain and numbness had responded to surgery, but incapacitating low back pain remained. See the x-rays below of the patient’s spine; note the different shapes of the ilia.Treatment focused on decompressing the spine and correcting the rotated ilia. Procedures included iliopsoas compartment blocks, bilateral sacroiliac joint injections, trigger point injections, and paravertebral injections. The patient also had a leg length discrepancy of 1.3 centimeters, and was ultimately fit with a 9 millimeter lift. A 9 millimeter lift was chosen because the patient exhibited decreased spine movement as a result of previous lumbar spinal fusion, and had advanced degeneration of the thoracic spine; the body would not be able to compensate for a complete correction. This necessitated a partial correction of the leg length discrepancy. The patient reported a significant decrease in pain, and was eventually able to walk for exercise.Case Study – Low back painA 27-year-old female patient had undergone two lumbar laminectomy procedures in an effort to treat low back pain; however, she did not experience pain relief. The patient’s job exacerbated her pain since she was constantly on her feet. Her neurosurgeon refused to consider further surgical intervention, and a friend referred the patient to the clinic. The patient was hypermobile, but had no history of a motor vehicle accident, major fall, or other trauma. Her lateral weightbearing spine film is pictured in below; note how one hip appears higher than the other. A leg length x-ray revealed a 1.1 centimeter discrepancy, and the patient was treated with an iliopsoas compartment block, thoracic paravertebral block; trigger point injections, and manual physical therapy. She tolerated a complete leg length correction, and ultimately experienced pain relief.