Two recent reviews in Neurology Clinics outline steps to take in the diagnosis and management of neck and back pain.

In noting that axial neck pain is a common and important problem in the outpatient setting, Prablek et al emphasize that neck pain, when it occurs as an isolated symptom, tends to have a musculoskeletal etiology that responds best initially to medication and targeted physical therapy. However, history and physical examination are required to make sure there are no additional neurologic symptoms.

If surgical intervention becomes indicated, there are several approaches to decompress the appropriate nerve root(s), such as the Cloward procedure, which can use banked bones or bone from the patient's hip to shore up the vertebrae. Although requiring general anesthesia, these procedures are generally fairly short (about 60-90 min), may be completed on an outpatient basis, are well-tolerated, and provide significant benefit for appropriately selected patients.

Back pain is common, affecting millions of patients annually. Gibbs et al recommend a biopsychosocial approach as providing the best clinical framework. They note the need for a detailed history and physical examination, including a thorough workup to exclude emergent etiologies, such as a herniated disc or nonoperative causes of back pain, such as musculoskeletal back spasms.

Management of back pain should first use conventional therapies such as lifestyle modifications, nonsteroidal anti-inflammatory drugs, physical therapy, and cognitive behavioral therapy. Only if these options have been tried with little or no success, and pain persists for longer than 6 weeks, imaging and referral to an orthopedic or spine specialist may be indicated.

The surgical procedure may be as simple as a single-level laminectomy, again in appropriately selected patients and performed either under neuraxial or general anesthesia on an outpatient basis, or a multilevel approach requiring the insertion of rods and screws and other instrumentation. This latter operation, requiring general anesthesia, may be prolonged and usually necessitates an in-hospital stay of 2 to 3 days with rehabilitation afterward. (See Prablek M, Gadot R, Xu DS, et al. Neck pain: differential diagnosis and management. Neurol Clin. 2023;41(1):77-85. doi:10.1016/j.ncl.2022.07.003; and Gibbs D, McGahan BG, Ropper AE, et al. Back pain: differential diagnosis and management. Neurol Clin. 2023;41(1):61-76. doi:10.1016/j.ncl.2022.07.002.)