Download - Approach to neck pain
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Approach to Neck Pain
Runal Shah3rd year Resident
Masters in Emergency Medicine
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Objectives
Causes
Clinical features– History– Signs & symptoms– Physical Examination
Differential diagnosis
Treatment
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Causes
– Trauma– Biomechanical injuries
– Degeneration– Inflammation (arthritides)– Infection (discitis, meningitis, epidural abscess)
– Infiltration (metastases, tumors)– Compression (epidural hematoma, abscess)
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Clinical features
Uncomplicated Joints Ligaments Muscles of the neck
Complicated Radiculopathy – Single nerve root
Myelopathy – Spinal cord lesion– Stenosis– Compression
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History to ask
Pain– Onset– Duration– Location
Trauma ?
Associated – Stiffness– Deformity– Neurological
Constitutional symptoms– Fever– Anorexia– Weight loss
Co-morbidity– Arthritis– Cancer
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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.
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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.
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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
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Examination
Movements– Forward flexion– Extension– Right & Left lateral flexion– Rotation to each side
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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.
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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.
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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.
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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.
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Neurovascular Examination
Reflexes
–Biceps : C5-6
–Brachioradialis : C6-7
–Triceps : C7-8
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Neurovascular Examination
Upper Limb Myotomes
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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.
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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)
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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
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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.
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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”
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2) Cervical Radiculopathy– Advice: Activity modification– Oral NSAIDs, muscle relaxants, opioids– Steroids : short course Prednisone x 7-10 days
– Follow up with Neurosurgery / Orthopaedics
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3) Cervical myelopathy– Patients with cord compression features should have
prompt follow up with Neurosurgery.– Decompressive surgery– Steroids and radiation for C-spine mets
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Conservative Treatment
– Physiotherapy
– Acupuncture
– Electrotherapy
– Manipulation
– Traction
– Thermotherapy
– Injection therapies
– Exercises
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References:Tintinalli 8/e
www.spine-health.com/glossary/radicular-pain-and-radiculopathyMCEM Part C: 110 OSCE Stations: Kiran Somani