Neck Pain – AFP 2013

Approach to Neck Pain
  1. Acute <6wk
    • most common: “locked” after quickly rotating the neck is typical of acute torticollis or the “wry neck” phenomenon
  2. Sub-acute: 6 weeks to 6 months
    • address yellow flags to reduce the transition to chronic neck pain
  3. Chronic >6months
Somatic Pain
  • Spondylosis – degenerative radiographic changes in the cervical spine are common in people over the age of 30 years. Attributing spondylosis as the cause of a patient’s pain is difficult, as radiographic changes are only weakly correlated with pain.
  • Discogenic – disc disease is also common and is again poorly correlated with patient symptoms. Axial pain is more severe than extremity pain in cervical discogenic pain.
  • Facet joint pain – pain is often midline or slightly paraspinal and somatic referral to the shoulders, scapular, upper limb or head are not uncommon.
  • Myofascial pain – this is a syndrome associated with trigger points. Characteristic features of trigger points include pressure sensitivity with reproduction of pain on palpation, taut muscle bands on palpation and limited range of movement following approximately  5 seconds of sustained trigger point pressure
Radicular pain
(neurogenic pain along a dermatome) – sharp with potential dysaesthesia or parasthesia.
  • Spondylotic myelopathy – degenerative changes that narrow the spinal canal, resulting in neurological compromise. Symptoms may include weakness, gait disturbance and bowel and/or bladder dysfunction. Optimal neurological recovery is dependent on early surgical decompression.
  • Cervical radiculopathy – causes are predominantly degenerative and include foraminal stenosis, such as those imparted by osteophyte encroachment from spondylosis. Another common cause includes posterolateral cervical disc herniation, compromising abutting exiting nerve roots.

Hx – ask about the pain and associated symptoms

PEx:

  1. Inspect: posture, symmetry, muscle bulk, scars
  2. Full cervical ROM
  3. Palpation: focal tenderness ↑ sinister pathology
  4. Neurological exam:
    • C1,C2 – neck flexion
    • C3 – side flexion
    • C4 – shoulder elevation
    • C5 – shoulder abduction, elbow/wrist flexion
    • C7 – elbow / wrist extension
    • C8 – thumb extension
    • T1 – hand intrisics
    • Reflexes
  5. Provocative manoeuvres (low sensitivity and specificity)
    • Neck compression
    • Upper limb tension

1. In patients with non-traumatic neck pain, use a focused history, physical examination and appropriate investigations to distinguish serious, non-musculoskeletal causes (e.g., lymphoma, carotid dissection), including those referred to the neck (e.g., myocardial infarction, pseudotumour cerebri) from other non-serious causes.

Neck Pain Red Flags
  1. Significant trauma – bony / ligamentous disruption of the c-spine
  2. Hx of Rheumatoid Arthritis – Atlanto-axial discruption
  3. Infectious symptoms (fever, meningism, hx of immunosuppression or IVDU): infection – epidural abscess, discitis, SAH, mycotic aneurysms
  4. Constitutional symptoms (fever, wt loss, anorexia, past or current hx of malignancy): Maligancy / infiltrative process, rheumatological dz (polymyalgia rheumatica, giant cell arteritis)
  5. Neurology (s/sx of upper motor neuron pathology): cervical cord compression, demyelinating process
  6. Ripping / tearing neck sensation: arterial dissection (carotid / vertebral)
  7. Concurrent chest pain, SOB, diaphoresis: MI
DDx
  • Carotid dissection – most common cause of stroke in young adults
  • Referred pain from ACS / MI
  • Infection: Retropharangeal abscess, epiglottitis
  • Spinal stenosis / spinal cord compression
  • disc herniation
  • nerve impingement
  • Whiplash
  • Lymphoma
  • Pseudotumor cerebri (referred pain from idiopathic intracranial HTN)
  • Muscular neck pain (posture, stress, etc)
Ix:
  1. In non-traumatic neck pain w/o red flags, imaging should generally be avoided
  2. Indications for imaging – starts with x-ray
    • Age >50 years with new symptoms
    • Constitutional symptoms (loss of weight, anorexia, fevers)
    • Infection risk (eg. immunosuppressed, intravenous drug use)
    • Moderate to severe neck pain lasting more than 6 weeks
    • Neurological findings
    • History of malignancy
  3. CT / MRI if malignancy, infection, spinal cord compression and disc herniation are suspected.
  4. When extremity, rather than cervical pain, is more severe with dysaesthesia then nerve conduction studies may also be useful.

2. In patients with non-traumatic neck pain, distinguish by history and physical examination, those attributable to nerve or spinal cord compression from those due to other mechanical causes (e.g., muscular).

spinal cord compression

  • increased pain with recumbency, movement, valsalva
  • pt has neurological symptoms (sensory ± motor)
  • Risk factors – cancer, Osteoporosis
  • Dx with MRI

3  Use a multi-modal (e.g., physiotherapy, chiropractic, acupuncture, massage) approach to treatment of patients with chronic neck pain (e.g., degenerative disc disease +/- soft neuro signs).

  •  Apart from exercise and physiotherapy, there is little evidence to support other conservative measures.
  • 1st line analgesics: Tylenol & NSAIDs – be used short term
  • Adress psychosocial barriers

4  In patients with neck pain following injury, distinguish by history and physical examination, those requiring an X-ray to rule out a fracture from those who do not require an X-ray (e.g., current guideline/C-spine rules).

It is important to remember that no assessment tool is perfect. If your instincts say ‘immobilise and image’ then that is probably what you should do.

Physical restraints are only of use in passive (either voluntarily or because of low level of consciousness) patients.

Canadian C spine rule (more sensitive than NEXUS)

  1. Trauma pt
  2. ≥ 16yo
  3. Stable VS
  4. No previous c-spine surgery or known vertebral dz
  5. No acute paralysis
    • with neck pain OR
    • visible injury above clavicle + non-ambulatory + dangerous mechanism of injury
X-ray if High risk factors:
  1. ≥ 65yo
  2. dangerous mechanism of injury:
    • fall ≥ 3 ft / 5 stairs
    • axial load to head. Eg. diving
    • MVA >100km/h, rollover, ejection, bicycle struck / collision, motorised recreational vehicles
  3. Paresthesias in extremities
X-ray if any low-risk factor absent:
  1. Simple rear end MVA
  2. Sitting in ED or walking at any time
  3. Delayed onset of neck pain (exclude pushed into oncoming traffic, hit by bus/truck, rollover, hit be high-speed vehicle
  4. Absence of midline C-spine tenderness
  5. Able to actively rotate neck 45 degree L and R

NEXUS – Low Risk Criteria

  • no posterior mid-line cervical spine tenderness
  • no evidence of intoxication
  • a normal level of alertness
  • no focal neurological deficit
  • no painful distracting injuries

adding ‘painless rotation to 45 degrees left and right‘ to the end of the NEXUS Low Risk Criteria makes it as sensitive as the Canadian C-spine Rule

If asymptomatic & NEXUS negative, may safely clear c-spine immobilization w/o radiographic evaluation.


5  When reviewing neck X-rays of patients with traumatic neck pain, be sure all vertebrae are visualized adequately.

C-spine radiographs:

Obtain the standard 3 views
  • Lateral
  • AP
  • Open mouth or Odontoid views
c1Then apply AABCDS for the Lateral views:c2

A. Adequate quality, particularly assuring that the Lateral includes the top of T1

  • CT if C7-T1 poorly visualized
  • MRI if neurological symptoms are present

A. Check Alignment, 4 lines

  • Anterior vertebral
  • Posterior vertebral
  • Spino-laminal
  • Spinous processes

B. Bony Landmarks.
Check each vertebra for shape and similarity to others, paying particular attention to the C1 and C2, or dens (odontoid peg) area.

  • Check the posterior bony elements for symmetry.c4c3
  • Trace the unbroken outline of each vertebrae (including Odontoid on C2).
  • Each body should be rectangular in shape and roughly equal in size although some variability is allowed. The anterior height of each body should roughly equal posterior height (posterior may normally be slightly greater, up to 3mm).
  • Pedicles project posteriorly to support the articular pillars, forming the superior and inferior margins of the inter-vertebral foramen.
  • Facet joints are osseous masses connected to the postero-lateral aspect of vertebral bodies via the pedicles. The facet joints are formed between each lateral mass.
  • “Double cortical lines” results from slight obliquity from lateral projection. The distance of the joint space should be roughly equal at all levels.
  • Laminae the are seen poorly on the lateral film.
  • Spinous processes generally get progressively larger in the lower vertebral bodies. The C7 cervical spine is usually the largest.

C. Cartilage space refers to the pre-dental space, which is < 3 mm in adults, and < 5 mm in children.c6c5

 

c7Widened pre-dental space

 

 

 

 

 

 

D. Disc spaces between the vertebrae should be symmetrical, allowing for differences in aging and c9degenerative changes.

S. Soft tissue swelling.

This is often the most difficult area of neck radiology interpretation.

C-spine fractures can occur and the only evidence on plain films is soft tissue swelling.

The measurements required are variable, so it is wise to have them recorded for easy reference.cc8

Level Adult Child
C1 <10mm <10mm
C3 <5mm <5mm
C5 <22mm <14mm
Then check the AP films for spinous process alignment and disc space symmetry
Finally, check the Open Mouth view forc10
    • dens symmetry
    • lateral body symmetry
    • fracture lines

up to 20% of injuries may be missed on c-spine x-rays. 

SCIWORA (Spinal Cord Injury Without Radiological Abnormality) –

  • most common in children and may be present in 1/3 to 2/3 of children with significant spinal cord injury
  • The condition may be delayed in presentation – sometimes neurological symptoms not appearing for 2 hours and even up to 24 hours. A thorough neurological assessment is required, and if neurological signs and symptoms develop, then immobilization, consultation and transfer are indicated.

References:
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Posted in 66 Neck Pain, 99 Priority Topics, FM 99 priority topics, Rheum

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