neck pain evaluation seniors

Evaluation of a Patient with Neck Pain

Introduction

Prevalence

Approximately 10 percent of the adult population has neck pain at any one time

Prevalence is similar to LBP

Point prevalence 10-15% in the USLife time prevalence 67-71%

2007 Task Force on Neck Pain• Grade I: No signs of major pathology and little

interference with daily activities

• Grade II: No signs of major pathology but may impact daily activities

• Grade III: Neck pain with neurological signs or symptoms (radiculopathy)

• Grade IV: Neck pain with major pathology:

– fracture, myelopathy, neoplasm, infections

Red Flags for Axial Neck Pain

• Advanced age• History of malignancy • Immunocompromised patient• Fever, Chills• Weight loss• Fatigue

• History of recent significant fall or

major trauma • Night time awakening• Severe non mechanical neck pain• Neurological signs or symptoms

( gait difficulty, bowel or bladder

dysfunction)

Anatomy of Neck

Anatomy of the Neck

• The cervical spine consists of seven vertebrae denoted as C1 – C7

• The bony anatomy of Atlas and axis are unique• The atlas is a ring, no vertebral body• The axis has a vertebral body with the

dense/odontoid peg • The odontoid form a true synovial joint with anterior

arch of the atlas.• C3-C7 vertebrae has fairly same anatomy

Cervical spine

Anatomy of Cervical Spine

Anatomy of Cervical Spine

Anatomy of Cervical Spine (Contd …)

• The atlantooccipital joint allows

– 1/3rd of flexion extension

– 50% of the lateral bending and

– 50% of the rotation

• The articulation between C3-C7 vertebrae allow

– rest of the movement.

Movements

Muscles of the neck

Muscles of the neck

Muscles of the neck

• originates on the sternum and clavicle • inserts on the mastoid process of the

temporal bone.• When contracted on one side it turns the

head sideways in the other direction. • When both sides contract, it pulls the head

forward and down

The sternocleidomastoid muscle

• extends upward from upper thoracic to the temporal bone.

• Contraction on one side causes the head to rotate and extend to one side.

• Contraction together causes extension of the head at the neck.

The Splenius capitus

• extends over the neck but is considered a superficial muscle of the back

• move the shoulder blade up and down • bring the head and neck in a backward

direction • rotate and side bend the neck

The trapezius

• extends upward from upper thoracic to the occipital bone.

• If one of the muscles acts alone the head is rotated to the side

• When the muscles contract together they extend the head at the neck ( along with the splenius capitus).

The semipinalis capitus

Muscles of the neck

Nerves

Nerves

Some Neck Pain Syndromes

Cervical Strain…

• Results from physical stresses of everyday life:

• poor posture

• sleeping habits

• Pathogenesis: Injury to paraspinal muscles

& ligaments → spasm of cervical & upper

back muscles

Cervical Strain

• Symptoms: acute axial neck and trapezius pain• Stiffness & tightness in upper back & shoulder

• No red flag• No neurological dysfunction• X-ray & APR normal• Lasts for up to six weeks

– Persistence beyond 6 wk– some other cause

Cervical Discogenic Pain…

• Commonest cause of neck pain

• Pathogenesis: Derangement of the disc architecture

• Symptoms: chronic axial neck pain

• Sometimes mild non-dermatomal shoulder and

limb pain

• Exacerbated when the neck is held in one position

for prolonged periods

• driving, reading, working at computer

Cervical Discogenic Pain• Signs: tightness/spasm on palpation

• Axial neck discomfort with range of motion

• Decreased range of motion

• Normal neurological examination

• Diagnosis is usually radiological

• MRI indicates progressive disc degeneration

• Vertebral bodies are normal

• No root impingement

Cervical Facet Syndrome… • Symptom: chronic midline/slightly one-sided

neck pain– Sometimes non-dermatomally referred to

• shoulders, around scapula, occiput, proximal limb

– Predisposition: most important clinical clue• Trauma with abrupt flexion-extension type injury• Occupation involving repeated neck positioning in

extension

– No red flag

Cervical Facet Syndrome

• Examination: no specific finding• Tenderness over the region of one facet joint

• X-ray: non-specific

• Relieved by fluoroscopically guided anesthetic injection into a facet joint

Whiplash Injury: Pathogenesis

• Caused by an abrupt flexion/extension of the cervical spine

• Multiple structures injured

• soft tissues, spinal nerve, intervertebral

disc, posterior longitudinal ligament,

interspinous ligaments, alar ligaments,

facet joints, or other osseous structures

Whiplash Injury: Features

• Severe pain, spasm, loss of range of motion in the neck and occipital headache

• Pain may be persistent

• Little identifiable abnormality seen on MRI, CT, X-ray, or bone scan imaging

• High resolution MRI: soft tissue damage at alar ligaments

Cervical Myofascial Pain

• Nonspecific manifestation of any

pathology causing neck pain

• Regional pain with trigger points, taut

bands, and pressure sensitivity

• Associations: muscle sensitivity,

depression, insomnia, fibromyalgia

Thoracic Outlet Syndrome

• Neck and shoulder pain with referred pain to the upper extremities

• The triad of numbness, weakness, and a sensation of swelling of the upper limbs

• Variable neurovascular signs and symptoms

• Examination may demonstrate a positive Adson's test

Cervical Spondylotic Myelopathy

• Degenerative changes narrowing spinal canal resulting in cord

injury/dysfunction• Features:

• Weakness

• Incoordination

• Bowel or bladder retention or incontinence

• Sexual dysfunction

• UMN signs in lower limbs

Causes of Neck Pain

Causes of Neck Pain….• Soft tissue lesions

o Acute neck straino Posture-related neck paino Whiplash injuryo Myofascial pain

• Degenerativeo Cervical spondylosisoDiscogenic neck paino Cervical disc prolapseo DISH

Causes of Neck Pain….

• Inflammatory arthropathieso RA, SPA

• Metabolic bone diseaseso Paget's disease, osteoporosis

• InfectionsoOsteomyelitiso Tuberculosis: retropharyngeal

abscess• Malignancy• Brachial plexus lesions• Referred pain, fibromyalgia, torticollis

Causes of Neck Nain.…

• Axial neck pain syndromeo Cervical straino Discogenic paino Cervical facet-mediated paino Cervical "whiplash" syndromeo Myofascial pain

Causes of Neck Pain• Predominantly cause extremity pain

oCervical radiculopathyoCervical spondylotic myelopathy

• Non-spinal causes of neck pain o Thoracic outlet syndrome o Herpes zostero Diabetic neuropathyo Infectionso Malignancy o Referred pain

Approach to A Patient

Evaluation

Steps : - History - Clinical examination - Investigations

History

• Onset of pain

• Acute pain – soft tissue lesions

• Chronic persistent pain- degenerative/metabolic

• Constant and increasing pain - mass effect

• Intermittent pain - instability or motion related pain

• Distribution of pain

• Well-localized pain - specific nerve root irritation

• Poorly localized pain-deep structures: muscles, bones, disc

• Duration

• Short duration generalized pain - benign pathology

• Longer duration - significant/ progressive pathology

History (Contd …)

• Character of pain

• Degenerative pain worsen as the day goes through

• Inflammatory pain worse in morning & associated with stiffness

• Neuralgic pain: from irritation of dorsal sensory root

• Myalgic pain: from irritation of the ventral motor root

• Aggravating factors/Relieving factors

• Myofascial pain worsen with neck flexion

• Discogenic pain worsen with neck extension or rotation

• Presence of neuralgic symptoms

• Sensory loss and weakness-compression of dorsal root

• Bowel/ bladder involvement- myelopathy

History (Contd …)

Important points:• Pseudo-angina pectoris may arise from cervical spine

• Should be differentiated carefully

• difficult when true and pseudo-angina coexist

• Dyspnea, cardiac arrhythmia and drop attacks may have cervical

spinal origin

• Eye, Ear & throat symptoms may be due to cervical spine disease

• Neck pain may manifest concomitant with systemic disease

Clinical Examination

Clinical examination includes • Look - observe gait, head and neck posture

• Feel - palpation of soft tissue surrounding neck

• Move - see the range of motion

• Other neurological examination

Clinical Examination (Contd …)

• Patient should be observed in sitting or standing position

• Should be looked from front, side & behind

• Anterior examination will establish whether neck is held straight or not (?torticollis)

• Lateral observation will establish whether normal curvature is maintained or not

• Posterior observation for C7 & T1 spinous process

• A short rigid neck may be associated with developmental anomaly

LOOK

Clinical Examination (Contd …)

• Muscle palpation- Local muscle tenderness can result from trauma

• Trapezius muscle tenderness is a non specific finding seen in-

Cervical muscle strain

Fibromyalgia, whiplash,

cervical radiculopathy

• Severe muscular rigidity and guarding are associated with severe neck strain, occult vertebral body fracture, or dislocation

FEEL

Clinical Examination (Contd …)

• Sternocleidomastoid muscle may be tender in whiplash injury

• Others to be palpated

Lymph node

Submandibular glands

Parotid glands

The thyroid

Carotid pulses

FEEL

Clinical Examination (Contd …)

Normal movements of the cervical spine

• Can bend 45 degrees laterally

• Can rotate an average of 90 degrees

• Less rotation is abnormal

• Can forward flex to 60 degrees

• Can extend backward 75 degrees

MOVE

Clinical Examination (Contd …)

Types of movement

If patient is able to comply safely with range of motion exercise then we should do

• Active ROM

• Passive ROM

• Motion against resistance

Clinical Examination (Contd …)

• Full extension- Tip of the nose and

forehead should form a horizontal plane.

• Anterior flexion- The chin should

allow touching the chest wall.

• Rotation- The chin should turn almost

to the shoulder in the coronal plane

• Lateral flexion- Move the shoulder up to the ear with gentle

restrain to the shoulder so that the neck flex laterally

Conditions Associated with Abnormal ROM….

• Cervical strain

• Cervical discogenic pain

• Cervical facet syndrome

• DISH

• Cervical radiculopathy

• Cervical myeloradiculopathy

Conditions Associated with Abnormal ROM

• Lateral is the earliest and most impaired movement in degenerative disease

• Rotation is first impaired in rheumatoid arthritis due to involvement of odontoid peg

• Movement is reduced in presence of muscular spasm or pain

• A uniformly stiff neck may be due to DISH, AS and recent trauma

Neurological Examinations

• Pain in a dermatomal distribution – Compression of dorsal root

Presence of neurological deficit

(Sensory loss and weakness)

- Minor or tolerable

- Disabling

• Long tract sign– Myelopathy

Location of Pain Source

Upper posterolateral cervical region C0-1, C1-2, C2-3

Occipital region C2-3, C3

Upper posterior cervical region C2-3, C3-4, C3

Middle posterior cervical region C3-4, C4-5, C4

Lower posterior cervical region C4-5, C5-6, C4, C5

Suprascapular region C4-5, C5-6, C4

Superior angle of scapula C6-7, C6, C7

Midscapular region C7-T1, C7

Localization of Pain Generators

• Provocative tests for radiculopathy:

o Spurling maneuver

– head extension

– ipsilateral rotation

– ipsilateral tilting

– application of pressure on head top

o The axial compression and traction test

• Provocative tests for myelopathy:

o Hoffmann's test

o Lhermitte’s test

Picture: Spurling maneuver

Provocative Tests

Adson's test:

The arm is gradually elevated in an

abduction arc

The examiner fingers are held on

the patient's radial pulse.

The patient is asked to turn his head

away from the tested side and take a

deep breath

If the pulse disappears as the arm

is abducted beyond 90 degree, test is

positive

Provocative Tests

X-ray cervical spine

Indications- • Neck pain with history of trauma

• Neck pain after age of 50

• Constitutional symptoms

• Neck pain not improved after conservative treatment

Investigations

Common views-

Lateral view• to see vertebral curvature

• to see degree of osteoarthritis

• disc space narrowing

• bony fracture (Compressed)

X-ray Cervical Spine

Oblique view

– to determine foramen

encroachment by osteophytes

X-ray Cervical Spine

PA View - • to see lateral deviation of the cervical spine in severe

torticollis

Odontoid view - • most appropriate in patients with acute trauma

X-ray Cervical Spine

MRI of cervical spine: Indications:• Red flags

• Objective neurologic impairment with weakness/reflex loss

• Evidence of cervical myelopathy

• Persistent moderate-to-severe symptoms despite conservative care

• Patients with dramatic bony tenderness combined with guarding

Investigations (Contd …)

MRI can detects • Disc herniations • ForamInal stenosis • Central canal stenosis• Tumor • Spinal cord changes from

myelopathy, fractures and infection

Investigations (Contd …)

When MRI Should Not be Done?• A low value on a pain rating scale less than 3/10

• Does not limit or interrupt daily activities– such as driving, desk work, or sleep

• Does not affect occupation

• Easily ignored when distracted

• Other reassuring features: – waxing and waning severity over years

– reasonable response to mild analgesics and heat

– “gelling” phenomenon (stiffness after prolonged single position)

– increase in symptoms with weather changes

Neurophysiologic investigations:• EMG, NCV, somatosensory evoked potential

Indications: • Clinical examination and imaging studies fail to correlate

• Conflicting information

• To differentiate intrinsic joint pathology from a radiculopathy.

• To differentiate cervical spine disorders from peripheral nerve entrapment syndromes

Investigations (Contd …)

Conclusions

Diagnostic Approach

• Neck pain is a common condition with enormous medical and legal costs

• Physicians need to differentiate causes of neck pain

• Knowledge of the anatomy helps diagnosis and the differentiation of symptoms

• The history and clinical examination help to focus the differential diagnosis and to identify the origin of pain

• Cervical discogenic pain is the most common cause of neck pain

• Cervical radiculopathy is most commonly due to degenerative changes

• CT/MRI should be done with specific indication

• Patient usually improves with conservative treatment if there is no significant disease

Take Home Message

Thank You