Neck painDr.Venugopalan PP

Director ,Emergency Medicine Aster DM Healthcare

Background Low back pain alone accounts for approximately 3% of all ED visits in the United StatesNearly one third of ED back pain patients receive x-rays10% undergo CT or MRI imaging Back pain is the number one cause of disability in the United States; neck pain is number four

Causes

Trauma and biomechanics injuriesDegenerationInflammation (arthritis), Infection (e.g., discitis, meningitis, and epidural abscess]Infiltration (e.g., metastatic cancer and spinal cord tumors)Compression (e.g., epidural hematoma and abscess).

Neck pain

• Three categories

• Uncomplicated -joints , ligaments and muscles

• Associated with Radiculopathy [Single nerve root ]

• Associated with Myelopathy [Spinal cord lesion , stenosis or compression ]

Explore through history

Onset,Duration, Location Trauma -recent or remoteAssociated symptomsStiffnessDeformityNeurologic complaints (e.g., weakness, changes in sensation, gait, or vision)Constitutional symptoms -fever, anorexia, and weight lossCo-morbid conditions - arthritis, cancer, and infections.

Pain evaluation

• P

• Q

• R

• S

• T

Rheumatoid arthritisAnkylosing spondylitisPsoriatic spondyloarthropathy

Involve the C1-C2 joint, Damage the transverse ligamentErode the odontoid processInstability of the atlanto-axial joint.Subluxation may occur spontaneously or following a trivial injury.

Explore through physical exam

Weight lossPallorAdenopathyAbnormalities of postureMovementFacial expressionPain may cause splinting of the head on the shoulders during position changeAssess active and passive movement, including rotation (chin to shoulder), lateral flexion (ear to shoulder), and flexion- extension (chin down, then up).

Spurling’ sign

Pushing down on top of head, with neck in extension (chin up) and head leaning toward symptomatic side elicits pain, typically toward or down the arm (positive Spurling’s sign); 90% specific, 45% sensitive.

Lhermitte’s sign

Flex neck forward until chin meets chest or pain stops movement. An electric shock sensation radiating down spine into both arms is a positive result (Lhermitte’s sign)

Abduction relief pain

Patient place the hand of the affected upper extremity on the top of his or her head to obtain relief, may indicate soft disk protrusion causing radicular pain.

Hoffman’s sign

Upper motor neuron lesion Flicking the tip of the middle finger as the hand is relaxed in a neutral position. A positive (abnormal) response is flexion of the thumb and index finger in a pinching motion

Tests

• Lab - useful only in infective pathology

• Imaging - Acute (days to weeks) - uncomplicated, nonradicular, nonmyelopathic, atraumatic neck pain typically requires no imaging because the cause is likely benign and the treatment is conservative.

ImagingThree-view cervical spine films

Chronic (weeks to months) neck pain with or without a history of traumaNeck pain and a prior history of malignancyRemote neck surgeryPreexisting spinal disorders such as rheumatoid arthritis, ankylosing spondylitis, and psoriatic spondyloarthropathy Flexion -Extension film -if instability is suspected, especially in patients with rheumatoid arthritis or other inflammatory arthritides.

Imaging

MRI is indicated for patients with chronic neck pain with neurologic signs or symptoms regardless of the plain radiographic findings. CT Myelography - if MRI is contraindicated

DD - Neck pain

• Mechanical neck disorders

• Cervical disc herniation

• Cervical spondylosis and Stenosis

• Cancer of cervical spine

• Cervical Myofacial syndrom

• Other conditions

Mechanical disorders

Hyperextension strainAcceleration-deceleration injuryHyperextension- hyperflexion injuryNeck strainNeck sprainWhiplash

Cervical disc herniation

Cervical disk herniations occur as the nucleus pulposus protrudes through the posterior annulus fibrosis, producing an acute radiculopathy or, occasionally, a myelopathy. Direct posterior rupture - Progressive Myelopathy Posterior lateral herniation - Radiculopathy Most frequent - C5-6 or C6-7

Cervical spondylosis and stenosis

Degenerative disk disease or osteoarthritisProgressive, degenerative condition Loss of cervical flexibilityNeck painOccipital neuralgiaRadicular painOccasionally progressive myelopathy. Progressive degeneration of the disks, ligaments, facet joints (zygapophyseal joints), and uncovertebral joints (joints of Luschka)

Cervical spondylosis

Radiographic diagnosis If any one of three findings is present: OsteophytesDisk space narrowing, Facet disease

Cervical spondylosis

Osteophytic spursEncroach posteriorly on the spinal canal- cervical myelopathyLaterally on the intervertebral foramen-cervical radiculopathyAnteriorly on the esophagus -dysphagia. Spurious osteophytes Horner’s syndromeVertebrobasilar symptomsSevere radicular symptoms without associated neck painPainless upper extremity myotome weakness,Chest pain mimicking angina

StenosisCervical spinal stenosis as the diameter of the spinal canal is reduced to less than 13 mm.

Cancer Cervical spine

Metastatic cancers

Unremitting night pain

Lung, Breast and Prostate cancers

Multiple myeloma & Lymphoma

MRI is the standard for the detection of spinal epidural metastatic disease and cord

compression,

Cancer patients with radiographic evidence of bone or disk margin destruction should undergo MRI

Cervical Myofacial SyndromeChronic neck painConfused with radiculopathyMyofascial pain symptoms may present or exacerbate acutely, especially after traumaPsychological distress & specific personality traits are risk factorsPain in the neck, scapula, and shoulder with or without nondermatomal radiation into the upper extremityTrigger point Neurology exam normalImaging nonspecific

Other causes

Infectious and inflammatory causesEpidural abscessOsteomyelitisTransverse myelitis

Non infectiousEpidural Hematoma Ischaemic heart disease Peripheral Nerve involvement - Carpal tuneo syndrome [Radicolopathy]Multiple sclerosis, Amyotrophic lateral sclerosis, Subacute combined degeneration, and Syrinx [Myelopathy]

ED disposition

• Neck pain

• Neck and arm pain [Radiculopathy]

• Myelopathy

Conservative treatment modalities

PhysiotherapyAcupunctureElectrotherapyManipulationTractionThermotherapyMedicinal and injection therapiesExercises

Uncomplicated Neck painAdvise to “act as usual” and avoid activities that produce painNonsteroidal anti-inflammatory drugs (NSAIDs)Muscle relaxants

Significant painShort course of oral opiatesNo NSAIDMuscle relaxant

Opiate is clearly superior to another in its class. Follow-up with the primary physician to assess the need for physical or manual therapies or additional medications.

Cervical radiculopathyWithout Myelopathy

Conservative activity modification to prevent symptom exacerbation injuryOral medications Immobilization with a soft or hard cervical collar is controversial without clear evidence for or against its use. Encourage follow-up with a primary physician Referral to a neurosurgical or orthopedic spine specialistElectrodiagnostic evaluationRehabilitation interventions

Oral medications may include NSAIDs, opioid analgesics, and muscle relaxants. A 7- to 10-day course of oral steroids (e.g., methylprednisolone or prednisone)

Cervical radiculopathy

Other treatment options in chronic casesEpidural steroid injectionSurgery Indications for hospital admission1. Progressive upper extremity weakness, especially in the C7

distribution2. Acute or progressive symptoms or signs of myelopathy3. Intractable radicular pain unresponsive to treatment.

Cervical Myelopathy

Cervical spondylotic myelopathy causes the greatest degree of impairment and disability Myelopathy is the most common cause of spastic paraparesis in patients older than 55 years of agePrompt neurosurgical or spinal orthopaedic consultationDecompression surgery Additional therapeutic considerations (e.g., steroids and radiation in spinal epidural metastases)

Thank you for patient listeningMain reference - Tintinelli 8th End