Approach to neck pain

Neck pain, almost everyone of us would have definitely suffered with neck pain once in our lifetime. So what is your approach for patient with neck pain? Is it just a sprain or something serious? Know the red flags of neck pain, and learn to examine neck systematically.

1. Approach to Neck Pain Runal Shah 3 rd year Resident Masters in Emergency Medicine

2. Objectives Causes Clinical features History Signs & symptoms Physical Examination Differential diagnosis Treatment

3. Causes Trauma Biomechanical injuries Degeneration Inflammation ( arthritides ) Infection (discitis , meningitis , epidural abscess) Infiltration (metastases, tumors) C ompression (epidural hematoma, abscess )

4. Clinical features Uncomplicated Joints Ligaments Muscles of the neck Complicated Radiculopathy Single nerve root Myelopathy Spinal cord lesion Stenosis Compression

5. History to ask Pain Onset Duration Location Trauma ? Associated Stiffness Deformity Neurological Constitutional symptoms Fever Anorexia Weight loss Co-morbidity Arthritis Cancer

6. 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.

7. 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.

8. 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

9. Examination Movements Forward flexion Extension Right & Left lateral flexion Rotation to each side

10. 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.

11. 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.

12. 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.

13. 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.

14. Neurovascular Examination Reflexes Biceps : C5-6 Brachioradialis : C6-7 Triceps : C7-8

15. Neurovascular Examination Upper Limb Myotomes

16. Imaging X Ray Anteroposterior (AP) Lateral Open-mouth Both oblique views CT Traumatic c-spine injuries MRI In patients with chronic neurologic signs or symptoms, regardless of radiographic findings.

17. 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)

18. 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

19. 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.

20. Treatment 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 ”

21. Cervical Radiculopathy Advice: Activity modification Oral NSAIDs, muscle relaxants, opioids Steroids : short course Prednisone x 7-10 days Follow up with Neurosurgery / Orthopaedics

22. Cervical myelopathy Patients with cord compression features should have prompt follow up with Neurosurgery. Decompressive surgery Steroids and radiation for C-spine mets

23. Conservative Treatment Physiotherapy Acupuncture Electrotherapy Manipulation Traction Thermotherapy Injection therapies Exercises

24. References: Tintinalli 8/e www.spine-health.com/glossary/radicular-pain-and-radiculopathy MCEM Part C: 110 OSCE Stations: Kiran Somani