Neck pain case presentation - Cervical spondylosis

This is an undergraduate case presentation on patient coming with a neck pain.

1. Neck Pain
25
th
Batch -Prof C -Group 1
Department of Family Medicine
Faculty of Medical Sciences
University of Sri Jayewardenepura

2. OUR TEAM
Karunaratne
Paranavithan
a
Kalupahana
Miswar
Karunanayak
e
Piyumika

3. INTRODUCTION
Mrs. XxxxxxXxxxxxxxxxxx
55 yrs
From Nugegoda
Occupation –Self-employed as a tailor
Married 2 children

4. Presented with
Neck pain for 4
months

5. History of the Patient
Known patient with DM for 5 years on oral (Metformin 500mg bd) + dietary
•Pain—insidious onset episodic pain for 4 months
•Site –in the back of the neck
•Worsened with time intense in last 2 weeks
•Severity -moderate, taken pcm
•No radiation to the shoulder or back
•Aggravated –movements of neck
•Relieved by resting and lying down
•Stiffness and restriction

6. Diferential
Diagnosis
•Cervical spondylosis
•Mechanical Pain (Posture, Trauma, Whiplash) –No Hx of injury to neck
•Cervical spinal CA –LOA
0
, LOW
0
, No past Hx of thyroid or breast CA
•Cervical disk herniation (Nerve root entrapment) –No tingling, numbness, weakness
of arms
•Rheumatoid arthritis –No pain, swelling, stiffness of small joints or knee, No night
sweating, no fever or chills

7. History of the Patient
•PMHx –DM
+
, HTN
0
•PSHx –nil
•Family Hx –DM
+
Mother, No family Hx of Malignancy, osteoporosis
•Allergy Hx –F
0
, D
0
, P
0
•Drug Hx –Metformin 500mg bd
•Social Hx –
•Patient -educated up to O/L
•Husband -three-wheeler driver, educated up to O/L
•2 school going children
•Lives in their own house
•Spends most of the time at sewing machine keeping neck bent down on
sewing
•Financially unstable
•Smoking
0
, Alcohol
0

8. History of the Patient
Concerns
•Is this a sinister condition
•Will I be able to recover completely
•Will this affect my occupation
•Will this end up in deformity
Expectatio
ns
•She had already been to a GP, prescribed with NSAIDs and had transient
improvements of symptoms, She wants the GP to diagnose her condition, She
wants a complete cure
•She finds its difficult to carryon her sewing workdue to pain, so she wanted a
pain relief

9. Red flag symptoms
•Significant preceding trauma or neck
surgery
•Systemic upset (weight loss, night
sweats, fevers)
•Severe pain
•Nocturnal pain
•Relatively young (<20) or old (>55)
•Signs of spinal cord compression
•Significant vertebral body tenderness
•History of TB, HIV, cancer or
inflammatory arthritis

10. Examination

11. Examination of the Patient
General
•Averagely built, Afebrile, no pallor
•No lymphadenopathy
•Normal gait
•No tenderness, swelling of small joints
•No rashes
Neck
•Look –No deformities, no visible lumps, no scars, swellings, muscle wasting in
the neck or upper limbs
•Feel -No tenderness over the spine
•Move –decreased range of all the neck movements
Neurology
•No weakness or altered sensation in upper or lower limbs

12. Examination
Movements

13. Specific tests

14. 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.

15. 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.

16. •Neck pain with restriction in movements could be
due to cervical spondylosis or mechanical neck pain
•Diabetic mellitus as a comorbid condition

18. Investigations
X-ray
CT, MRI
•If neurologic signs present or Red flag signs refer the patient for relevant
specialityfor further investigations or management
•If the diagnosis is in doubt or if the patient is particularly requesting it, an X-ray
of the cervical spine may be useful.
•–Anteroposterior (AP)
•–Lateral

19. Management

20. Management
Non-pharmacological
Pharmacological
•NSAIDS
•COX-2 inhibitors like Celecoxib are preferred
•Considering patient's socioeconomic status non-selective COX inhibitor
with Proton pump inhibitor can be given
•Cervical collar
•Teach exercises to do at home
•Physiotherapy

21. Prevention
Primary prevention
Secondary Prevention
•Avoid long hours of working at the sewing machine
•Adherence to treatment, regular follow up
•Diabetic screening, drug compliance and regular clinic
follow up
•Proper health education and promotion to prevent
abnormal posturing
•Educating general public about importance of healthy
diet and exercise

22. •In 4 weeks and assess
•Pain
•Functional level
•Exercise compliance

23. Discussion

24. Discussion
Mechanical neck disorders
•Causes
•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.
•Symptoms -Acute pain following trauma increased by
movements of neck
•Investigation: X-ray
•Management: Cervical collar, Pain management

25. Discussion
Cervical Spondylosis
•Natural wearing down of cartilage, disks, ligaments and bones in
the neck
•Main symptoms: Neck pain, stiffness, headache, pain in the
shoulder or arms
•At severe stages –difficulty in walking, loss of coordination
•Risk factors: Age, Smoking, overweight, repetitive neck
movements, genetics

26. Discussion
Cervical Spondylosis
•Examination:
•Spurling sign –radicular pain increased
by extension and lateral bending of the
neck towards side of lesion causing
foraminal compromise
•Lhermitte sign –Neck flexion
causes generalized electrical
shock sensation

27. Discussion
Cervical Spondylosis
•Investigation: X-rays
•Management:
•Rest
•Medications (NSAIDs, Corticosteroids, Muscle relaxants, antidepressants)
•Ice, Heat
•Physiotherapy
•Exercise
•Steroid based injections
•Surgery

29. Discussion
Cervical disk herniation
•Nucleus pulposus protrudes through the posterior annulus
fibrosis, producing an acute radiculopathy
•Symptoms –Pain, weakness, numbness in the distribution
of affected nerve

30. Discussion
Cervical disk herniation
•Most common level
•C5-C6 (C6 nerve root)
•C6-C7 (C7 nerve root)

31. Discussion
Cervical disk herniation
•Risk factors –Heavy weightlifting, smoking, operating
vibrating equipment
•Examination
•Positive Spurling’s test
•Positive distraction test
•Cervical rotation > 60
0
•Investigations: MRI
•Management (NSAIDs for pain, Physiotherapy, Referral for
Surgery)

32. Discussion
Spinal CA
•85% are metastasis
•Any type of cancer can spread to
bones, but most likely are
•CA Lung, breast, prostate, thyroid
•Primary: multiple myeloma, lymphoma
•Symptoms: Neck pain associated with LOA, LOW, SOB,
Hemoptysis, breast lump
•Risk factors: Elderly, Past or family Hx of Malignancy,
exposure to radiation etc.
•Examination: neck lump, deformities, systemic examination
•Investigations: MRI
•Management: Surgery / Oncology referral

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