Approach to Neck Pain

Runal Shah3rd year Resident

Masters in Emergency Medicine

Objectives

Causes

Clinical features– History– Signs & symptoms– Physical Examination

Differential diagnosis

Treatment

Causes

– Trauma– Biomechanical injuries

– Degeneration– Inflammation (arthritides)– Infection (discitis, meningitis, epidural abscess)

– Infiltration (metastases, tumors)– Compression (epidural hematoma, abscess)

Clinical features

Uncomplicated Joints Ligaments Muscles of the neck

Complicated Radiculopathy – Single nerve root

Myelopathy – Spinal cord lesion– Stenosis– Compression

History to ask

Pain– Onset– Duration– Location

Trauma ?

Associated – Stiffness– Deformity– Neurological

Constitutional symptoms– Fever– Anorexia– Weight loss

Co-morbidity– Arthritis– Cancer

Signs & Symptoms

Radicular pain– A type of pain that radiates into the lower extremity directly

along the course of a spinal nerve root.– Caused by herniated disc, foraminal stenosis and peridural

fibrosis.

– Sharp, burning, intense pain that radiates to the trapezius, periscapular area, or down the arm.

– Weakness or paresthesias may develop weeks after pain onset.

Myelopathy pain– Neck pain that progresses insidiously.– Clumsy hands, gait disturbances, and sexual or bladder

dysfunction.– Due to a spinal cord lesion, stenosis, or compression.

Examination

Inspection– From FRONT, BACK & SIDE.– Look for swelling, deformity, scar, muscle wasting

Palpation– Stand BEHIND & to the SIDE of the patient.– Palpate from Occipital cervical to thoracic vertebra – from

midline laterally– Anterior neck & Supraclavicular fossae palpation

Examination

Movements– Forward flexion– Extension– Right & Left lateral flexion– Rotation to each side

To check Spinal Cord Compression

Hoffman’s Test– Elicits a pathological reflex

present in spinal cord compression.

– Hold the middle finger at the middle phalanx between the index and middle finger of the examiner’s hand. Flick the distal phalanx at the pulp with the examiner’s free thumb.

– The test is positive if the patient’s index finger and thumb flex.

To check Spinal Cord Compression

• Lhermitte’s Test– Barber’s chair

phenomenon– Flexion / extension of the

neck produces electric shock like sensation in the legs.

– This sign is mostly associated with multiple sclerosis.

Signs of Meningism Kernig’s Test

– Performed with the patient supine or in a chair.

– The hip and knee are flexed to 90° and attempt is made to extend the knee.

– The test is positive if the manoeuvre causes pain in the neck or back.

Brudzinski’s Test– Flexion of the neck causes

flexion of the hips and knees.

Signs of Thoracic Outlet Obstruction

Adson’s Test– Palpate the radial pulse and,

while keeping the elbow extended, abduct (to 30°), externally rotate and extend the shoulder. Then ask the patient to take a deep breath and hold in inspiration and turn the head to the ipsilateral side.

– The test is positive if there is a loss of the radial pulse.

– Always compare with the other side.

Neurovascular Examination

Reflexes

–Biceps : C5-6

–Brachioradialis : C6-7

–Triceps : C7-8

Neurovascular Examination

Upper Limb Myotomes

Imaging

1) X Ray– Anteroposterior (AP)– Lateral– Open-mouth– Both oblique views

2) CT– Traumatic c-spine

injuries

3) MRI

– In patients with chronic neurologic signs or symptoms, regardless of radiographic findings.

Differential diagnosis

Mechanical neck disorders– Motor vehicle collisions– Falls– Sports injuries– Work-related injuries– Strain injury, caused by an

awkward position during sleep or prolonged abnormal head-neck positions during work or recreation.

Cervical Disc Herniation– Nucleus pulposus

protrudes through the posterior annulus fibrosis, producing an acute radiculopathy or, occasionally, a myelopathy.

– Most common level :• C5-6 (C6 nerve root)• C6-7 (C7 nerve root)

Differential diagnosis

Cervical spondylosis/ stenosis– Progressive, degenerative

disease (Osteoarthritis)– Loss of cervical flexibility,

neck pain, occipital neuralgia, radicular pain.

– Occasionally progressive myelopathy.

Cervical spine Cancer– Metastases to consider for

chronic neck pain– Ca Lung, breast, prostate

and multiple myeloma, lymphoma forms most common 1°pathology.

– MRI

Differential diagnosis

Cervical Myofascial Pain Syndrome– A cause of chronic neck pain, often confused with

radiculopathy.– May exacerbate acutely after trauma.– Psychological stress and specific personality traits are known

risk factors.

– Typically, pain in the neck, scapula, and shoulder ± non dermatomal radiation into the upper limb.

– Tender spots, “trigger points” may be evident on palpation of the head, neck, shoulder, and scapular region. Neurologic examination is normal.

Treatment

1) Uncomplicated Neck pain– NSAIDs– Muscle relaxants– Short course Opioids– Soft Collar – reduces 20% neck movements – to be

given for < 10 days

– Advice – “Act as usual”

2) Cervical Radiculopathy– Advice: Activity modification– Oral NSAIDs, muscle relaxants, opioids– Steroids : short course Prednisone x 7-10 days

– Follow up with Neurosurgery / Orthopaedics

3) Cervical myelopathy– Patients with cord compression features should have

prompt follow up with Neurosurgery.– Decompressive surgery– Steroids and radiation for C-spine mets

Conservative Treatment

– Physiotherapy

– Acupuncture

– Electrotherapy

– Manipulation

– Traction

– Thermotherapy

– Injection therapies

– Exercises

References:Tintinalli 8/e

www.spine-health.com/glossary/radicular-pain-and-radiculopathyMCEM Part C: 110 OSCE Stations: Kiran Somani