# Vertebral Pain in Acute COVID-19--Cases Report
## 4 Discussion  
As shown, the vertebral pain was reported as the first complaint of COVID-19 in four physically active adults. Three patients had no previous history of vertebral algic syndrome or back pain. One patient complained of minor neck pain with no need for treatment. At the \begin{table}
\begin{tabular}{c c c c c} \hline
**Patient** & **Gender** & **Age (years)** & **Pre-COVID-19 VAS** & **Peri-COVID-19 VAS** & **Post-COVID-19 VAS** \\ \hline
1 & M & 32 & 1 & 5 & 0 \\
2 & F & 38 & 0 & 7 & 0 \\
3 & M & 43 & 0 & 7 & 2 \\
4 & M & 45 & 0 & 6 & 0 \\ \hline \end{tabular}
\end{table} 
Table 1: VAS score in four patients prior to, during, and after COVID-19 infection. Figure 1: Minor morphological changes in MRI scan of cervical spine in 38-year-old woman with migrating pseudoradicular symptoms in COVID-19 without previous history of cervical vertebral algic syndrome. (**a**) Sagittal T2-weighted sequence; (**b**) Axial T2-weighted sequence. time of neurosurgical examination and during acute COVID-19 infection, the vertebral pain dramatically increased, whereas no other clinical manifestation of SARS-CoV-2 infection was present. The infection was coincidentally confirmed afterwards. The course of COVID-19 was not severe; only symptomatic therapy was needed. Great variability and changes in intensity of the pain and cervical/lumbar pseudoradicular symptoms were present. The pain characteristics did not correspond with the findings of neuroimaging. Similarly to our clinical experiences, significant increases in musculoskeletal pain in COVID-19 patients during the course of disease in cervical (up to 46.6%) and lumbar spine (to 50.7%) were reported by [PERSON] et al. [27]. Extra-pulmonary musculoskeletal symptoms were commonly present among COVID-19 patients [7; 8; 12; 13; 27]. The central nervous system involvement has been studied on a deeper level, and some interesting hypotheses have been developed in published studies (headache, encephalitis, worsening of cognitive functions, onset/worsening of psychiatric disorders, Guillen-Barre syndrome, loss of taste and/or smell [11; 12; 14]), but the back pains remain unclear. The relationship between musculoskeletal pain and COVID-19 severity varied among the studies. While [PERSON] and [PERSON] [6] reported that the occurrence of muscle pain was not associated with increased severity, [PERSON] et al. [18] suggested that myalgias were an important predictive factor for the severity of the overall disease in patients with abnormal computed tomographic or radiographic imaging of the lungs. When the disease resolved, the pain intensity dropped in a majority cases to the pre-infection level. However, other authors found that pain associated with COVID-19 could continue in the post-infection period [27] and could become chronic [11; 13]. There is no question that an improved understanding of the rare symptoms of acute COVID-19 is needed. The viral load in patients with vertebral alic syndrome as the first/only symptom of SARS-CoV-2 infection could be similar to that of patients with asymptomatic or other manifestations of the novel coronavirus disease [28; 29]. Therefore, closer attention should be paid by examining physicians. Because clinical manifestations of novel coronavirus infection can be widely variable in clinical presentation and pain intensity, it seems impossible to distinguish SARS-CoV-2-associated vertebral pain on the basis of clinical and radiological examination. The PCR test should be performed on suspicion of COVID-19-associated vertebral pain, especially in young, middle-aged, and physically active persons presenting acute onset of vertebral pain without a history of trauma. The mitigation of musculoskeletal pain in patients with COVID-19 might lead to further infection and unnecessary treatment. The findings of this study have to be viewed in light of the limitation of its small sample size. The neurosurgical patients in our study most likely represent only the tip of the COVID-19-associated vertebral pain iceberg.