Examinations of the Neck and Back Region

A neurological exam is a systematic assessment of cognitive, sensory, and motor responses to identify pathologies of the nervous system. A neurological exam allows for the localization of neurologic lesions to narrow the differential diagnosis and focus on subsequent laboratory and imaging examinations. The exam should include assessments of the subject's mental status, speech, cranial nerves, motor system, deep tendon reflexes, sensation, balance, and coordination.

The muscles of the neck can be divided into 3 groups: anterior, lateral, and posterior neck muscles. Each of the groups is subdivided according to function and the precise location of the muscles. The muscles of the neck are mainly responsible for the movements of the head (i.e., extension, flexion, lateral flexion-extension, and rotation), but the deep muscles also contribute to more intricate functions (i.e., speaking and swallowing).

The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. The spinal cord is divided into cervical, thoracic, lumbar, and sacral regions, though because the spinal cord is shorter than the vertebral column, these regions do not line up with their corresponding vertebral levels. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Like the brain, the spinal cord is surrounded by 3 layers of connective tissue, collectively known as the meninges; these layers are the dura mater, arachnoid mater, and pia mater. The spinal cord is supplied by 1 anterior and 2 posterior spinal arteries.

Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Musculoskeletal conditions can range in severity from simple strain to radiculopathy and myelopathy. A careful history and physical examination is essential in discovering the etiology and guiding therapy. Treatment of the majority of cases of neck pain is conservative and activity-based.

Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. A thorough history and physical examination is necessary to guide the diagnosis. Additional workup is not required unless evidence of severe diseases exists (e.g., neurologic deficits, urinary/fecal incontinence, infectious symptoms, or malignancy). Management varies depending on the cause, but most cases are managed with conservative measures and analgesics.

Upper motor neurons (UMNs) and lower motor neurons (LMNs) combine to form a neuronal circuit for movement. UMNs are responsible for carrying motor information from the cerebral cortex and brain stem to the spinal cord, and LMNs carry motor information from UMNs in the spinal cord to the skeletal muscles for movement. Upper motor neuron lesions cause damage to neurons above the motor nuclei of the cranial nerves in the brain stem or the anterior horn cells in the spinal cord. These lesions present clinically with symptoms of weakness, spasticity, clonus, and hyperreflexia. Causes include stroke, traumatic brain injury, brain cancer, infectious and inflammatory disorders, and metabolic and neurodegenerative disorders. Lower motor neuron lesions affect the nerve fibers traveling from the anterior horn of the spinal cord to the peripheral muscle. These lesions present clinically with muscle weakness, atrophy, and hyporeflexia, with sensation remaining intact. Diagnosis is made by clinical neurologic exam, and management is mostly supportive, but some newer therapies have recently become available.