Back and Neck Pain

An Overview of Back and Neck Pain

Obviously enough, neck and back pain is simply the experience of unpleasant sensations in the area of your neck, your mid, and/or upper back, or your low back. As you will see, spine pain can be brought about by any number of things, can be understood in a myriad of ways, and may bring on symptoms in other areas of your body.

Spine pain is very common, with low back pain affecting up to 80 percent of the population at some time in their lives.

There's almost twice as much low back pain as neck pain, and the amount of low back pain and knee pain are about equal.

Who Gets Back and Neck Pain?

You may be at a higher risk for spine pain if you're female, you're overweight or obese, you smoke, have osteoporosis and/or you either get too much exercise or not enough. Other risk factors include a lower education level, living in an urban area, being under 50 (for neck pain) and under 65 (for low back pain), higher stress levels, or having emotional difficulties (anxiety or depression).

On-the-job factors play a big role in neck and back pain risk, too. If you're dissatisfied with your job, you lack support from your co-workers or bosses, or your job involves subjecting your body to vibration (for example, operating a jackhammer) you may have a higher likelihood of a painful spine. Office workers tend to get more neck pain than do other types of workers.

Much less is known about mid and upper back pain than about neck or low back pain. This is mainly because the research on this topic is limited. But a 2016 study published in the European Journal of Pain suggests that it is just as common as neck and back pain.

While neck and back pain are rarely, if ever, life-threatening, they can be quite bothersome and in some cases can seriously disrupt your quality of life for a long time. That said, most cases turn out to be minor episodes that people recover from by reducing their activity and letting the problem take its course.

Back and Neck Pain - The Technical Considerations

If we're going to get technical about it, the neck (and therefore neck pain) is defined as (pain in) that part of the spine extending from your first cervical vertebra (which is approximately at the level of the bottom of your ear lobe) down to the seventh. The seventh cervical vertebra is located at the top of your shoulder and upper back. 

The mid and upper back is next, extending from just below the 7th cervical vertebra down to the bottom of the 12th thoracic vertebra. The 12 thoracic vertebra lines up approximately with the tip of the rib that is third from the bottom (technically called the 10th rib.) This rib is the last of the "true" ribs (i.e., it is attached to the breastbone by means of cartilage in the front).

Below the 10th rib are two more—these are called "floating ribs" because they do not circle around to the front and are not attached to the breastbone.

The low back is the area corresponding to the lumbar spine, which starts below the 12th thoracic vertebra and extends down to the top of the sacrum bone, almost mid-way down between the two back hip bones. Sacroiliac and coccyx pain are also types of spine pain; mainly sacroiliac pain takes the form of sacroiliac joint dysfunction. The coccyx bone is your tailbone. It is the last bone of the spine; it hangs down off the bottom of the sacrum.

How to Understand Spine Pain

There are many ways to describe, understand, and diagnose spinal pain. You could look at it in terms of how long you've had it; recent pain is called acute, while pain lasting longer than three months is known as either chronic or persistent pain. A very common cause of chronic spine pain related to aging (and to a lesser degree long-standing injuries) are the degenerative changes in spinal structures that occur from wear and tear over time.

Acute and chronic pain are treated very differently from one another, by the way.

Or you could understand spine pain in terms of nerve symptoms. If you have pain, weakness, numbness and/or electrical type sensation that go down one arm or one leg, you may have a condition called radiculopathy. Radiculopathy is an irritation of one or more spinal nerve roots, and is often—but not always—caused by an injury known as herniated disc. Spinal nerve roots are a collection of nerves that have branched off from the main, central spinal cord and are on their way out to serve all areas of the body. Each spinal bone has two spinal nerve roots (one on either side) that exit from the spinal cord. When something presses on the nerve root, the nerve root may become irritated, leading to pain and the other symptoms mentioned above. Again, this can be due to a herniated disc but may also come about by arthritic (degenerative) changes in the spine, such as facet joint hypertrophy, spinal stenosis, bone spurs, and more.

Another way to understand neck and back pain is in terms of how it started. Did you have an accident or other trauma? Diagnoses in these cases can include whiplash, herniated disc, muscle sprain or ligament strain, spinal fracture, or spinal cord injury.

But if the pain seems to grow on you slowly, it may be due to poor posture or spinal deformity, such as scoliosis. Pain that develops over time may also be due to degenerative, age-related spinal changes, such as those mentioned above, that often lead to spinal arthritis and possibly spinal stenosis.

More rarely, neck or back pain is caused by systemic problems such as diseases, tumors, or cysts. Your diagnostic work up will likely include screening for "red flags," which are signs to your doctor that may cause her to suspect a systemic rather than a structural problem. Genetic and congenital causes are also possible. Examples of congenital spine conditions include spina bifida and congenital torticollis (torticollis means "twisted neck"). And Scheuermann's kyphosis, a deformity that affects some teen boys, is an example of a spinal condition related to genetics.

Spinal pain related to the above causes can occur in pretty much any region - cervical, thoracic (mid and/or upper back), lumbar sacral, or coccyx. Along with the vertebrae, discs, nerves, and muscles, neck and back pain may affect or be affected by organs and glands in the area as well as blood vessels.

Spine Care Industry—Is It Buyer Beware?

Many members of the conventional medical establishment, including doctors, researchers, physical therapists, and others, are highly focused on evidence-based treatments for their neck and back pain patients. What this means is they want to see the proof that the therapy or surgery works before they'll use or recommend it.

And to a great extent, this is good. With healthcare the booming industry that it is, scientific evidence is key to treatment that delivers pain relief and improved quality of life. But the potential for over-treatment is decidedly there. Worse, doctors often prescribe treatments that haven't been proven to work in a safe and effective manner for patients —even though they should, and even though patients depend on them to do so. 

For example, many doctors prescribe opioids as a first line treatment for even mild cases of spine pain. But this may not always be necessary. A 2016 systematic review and meta-analysis found that most people taking narcotic pain relievers for back pain (also known as opioids) did not get "clinically important pain relief" in the dosage range evaluated. The review/meta-analysis concludes that people who tolerate opioids may get "modest short-term relief" at best, and that there's really no evidence to speak of for long-term pain relief.

Just the same, the use of opioid pain relievers is increasing steadily, especially for muscloskeletal disorders. The National Medical Expenditure Panel Survey revealed a 104 percent increase in opioid prescriptions in 2010, and one researcher reports that about half of opioid users have back pain. He comments that the use of opioids for chronic back pain is controversial due to its potential safety and effectiveness issues.  

As narcotics, this type of medication comes with a risk for addiction.  Before consenting to the prescription or taking the drug, it's best to weigh its potential for addiction as well as other side effects (such as constipation) against pain relief that you could possibly get through other means. 

Another hot button issue in spine treatment is the overuse of diagnostic imaging. Many doctors order a full workup for their patients with back pain—even the mild cases that are likely to resolve on their own.  

In a 2009 study entitled, "Overtreating Chronic Back Pain: Time to Back Off?," which was published in the Journal of the American Board of Family Medicine, author Rick Deyo, M.D., PhD., found that even though guidelines for doctors strongly discourage using imaging tests when they are not necessary (mainly because of the resulting unnecessary medical costs), the number of lumbar spine MRIs  increased by 307 percent in the 12 years following 1990. The author also notes that the rate of imaging tests given to spine patients varies "dramatically" across the country and that back surgery rates are highest where the imaging rates are also the highest. 

Deyo suggests that up to two-thirds of the imaging tests given may be done so inappropriately.

A 2016 study published in the Permanente Journal found that people with public insurance got spine MRIs more frequently than those with either no insurance or private insurance.

Deyo also notes the things that may be driving this upward trend in the use of diagnostic imaging for low back pain: The growth of the imaging sector of the healthcare industry, increases in patient demand for MRIs, "the compelling nature of visual evidence," as Deyo puts it, lawsuit threats, and money.

Back surgery is another area where over-treatment may be rampant. In the same article mentioned above, Deyo says that rate of spinal fusions performed during the 12-year period increased by 220 percent. The author noted a trend toward more surgery (and of course higher costs) for those patients who got MRIs early on in their course of treatment. The problem is, these surgeries did not, overall, improve patients' pain levels or ability to function, he concludes.

Generally, research recommends trying physical therapy and other conservative treatment for six weeks.  If the therapy (and your participation in it) fails to relieve the pain, at that point surgery may be a possibility. But many doctors don't offer their spine patients a prescription to PT.  Should this be the case between you and your physician, advocate for yourself by asking for it. And if she tries to push you into back or neck surgery before you're convinced, it may be time to seek a second opinion.


Abdel Shaheed C. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain A Systematic Review and Meta-analysis. JAMA Internal Medicine. July 2016.

Deyo RA, Mirza SK, Turner JA. and Martin BI. (no date) Overtreating chronic back pain: Time to back off? 22(1).

Gold R, Esterberg E, Hollombe C, et al. (2016) Low back imaging when not indicated: A descriptive cross-system analysis. The Permanente journal., 20(2), pp. 25–33.

Johansson, Stochkendahl J, Hartvigsen J, Boyle E. and Cassidy J. (2016) Incidence and prognosis of mid-back pain in the general population: A systematic review. European Journal of Pain (London, England).

Sites B, Beach M, and Davis M. (2013) Increases in the use of prescription opioid analgesics and the lack of improvement in disability metrics among users. Regional Anesthesia and Pain Medicine., 39(1), pp. 6–12.

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