Neck pain

Background

• Two types:
  • 1. Musculoskeletal
  • 2. Radiculopathy/myelopathy

Clinical Features

• Musculoskeletal
  • Pain is deep, dull ache, episodic
  • History of excessive or unaccustomed activity
  • Pain is localized and asymmetric
  • Referred pain: head (upper cervical segments), limb girdle (lower cervical segments)
  • Symptoms aggravated by neck movement, relieved by rest
• Radiculopathy
  • Pain is sharp or burning
  • Radiates to trapzezial and periscapular areas or down arm
  • Numbness/weakness in myotomal distribution
  • HA may occur if upper cervical roots are involved
  • Symptoms aggravated by neck hyperextension (esp when head is toward affected extremity)
  • Gradual onset of shocklike sensations spreading down spine to extremities
  • Most common at level of 5th cervical vertebra (shoulder abduction, external rotation)

DDX

• Musculoskeletal
• Cervical disk herniation
• Cervical spondylosis
• Cervical stenosis
• Cancer
• Epidural abscess
• Vertebral osteomyelitis
• Transverse myelitis
• Temporal arteritis
• Epidural hematoma (anticoagulation, hemophilia)

Diagnosis

• Musculoskeletal pain
  • Pain occurs on side away from head movement
• Radiculopathy
  • Spurling test
    • Apply gentle pressure to pt's head during extension and lateral rotation
    • May reproduce pt's radicular pain w/ radiation into ipsilateral upper extremity
  • Abduction relief sign
    • Placing hand of affected extremity on top of head leads to relief
    • Indicates soft disk protrusion

Imaging

• Consider x-ray for:
  • Chronic neck pain (weeks-months)
  • History of malignancy
  • History of RA, ankylosing spondylitis, psoriatic spondyloarthropathy
• Consider MRI for:
  • Neurologic signs/symptoms
  • Plain films show bone or disk margin destruction
  • Cervical instability
  • Epidural abscess is suspected

Specific Disorders

Whiplash Injury

• Sudden acceleration-deceleration trauma that occurs when car is rear-ended
• Pain, stiffness, paracervical muscle tenderness
• Use C-Spine (NEXUS) criteria to determine whether imaging is required
• Consider brain, cord, carotid/vertebral artery dissection if neuro findings are present

Cervical Disk Herniation

• Nucleus pulposus protrudes through posterior annular fibrosis
  • Leads to radiculopathy or less commonly myelopathy
• Neck/shoulder/arm pain in dermatome distribution, weakness, hyperreflexia
• MRI required for diagnosis

Source

• Tintinalli