Neck Pain

Defining Neck pain

Neck pain is pain and discomfort occurring anywhere between the base of the skull and

thorax. Can occur anteriorly, posteriorly or laterally.

AS SOON AS YOU SEE THE DOORWAY INFORMATION, A BROAD DIFFERENTIAL DIAGNOSIS SHOULD STRIKE YOUR MIND

Mnemonic: "Mike SEARCHES The COW"

M – Meningitis/ Metastasis S - Spasmodic torticollis

EA - Epidural abscess

R - Rheumatoid arthritis

C - Cervical strain/ disc herniation

HE - Herpes zoster

S - Spondylosis T - Thoracic Outlet syndrome

C - Cervical fracture/ dislocation/ myelopathy

O - Osteoarthritis/ Osteomyelitis/ Overuse

W – Whiplash injury

NECK PAIN

ANTERIOR

POSTERIOR

BASE OF THE SKULL

Lymphadenitis

Torticollis

Esophagitis

Painful thyroiditis

Pharyngitis

Carotidynia

Carotid artery dissection

Aortic dissection

Occipital neuralgia

Migraine

Musculoskeletal

- Cervical strain - Disc Herniation

- Degenerative disk disease - inflammatory arthritis - Cervical fracture - Cervical stenosis

- Whiplash - Fibromyalgia

Neurologic

- Thoracic outlet syndrome

- Myelopathy - Radiculopathy - Peripheral Neuropathy

Infectious

- Discitis - Osteomyelitis

- Meningitis - Cervical lymphadenitis

Neoplastic

- Spinal cord

tumour - Primary neck neoplasm - Malignant neoplasm

Referred

- Rotator cuff

tendinopathy - Myocardial ischaemia - Pneumonia

Presenting complaint

Ask open ended questions to elicit the patient’s presenting complaint: “So what’s brought you in today?” or “Tell me about your symptoms” Try not to interrupt or direct the conversation, provide time to express themselves If required ask the patient to expand on their presenting complaint by: “Ok, so tell me more about it” “Can you tell me about the pain? How would you describe it? History of presenting illness (HOPI)

OSDP LIQRAAA PF ONSET

When did your neck pain first begin?

Do you remember what you were doing when the pain started? SITE

Where exactly do you feel the pain?

Can you point it out with a single finger?

DURATION

How long have you been experiencing it?

Is it present throughout the day or just comes n goes?

PROGRESSION

Since the pain started, is it the same or becoming worse? INTENSITY

On a scale of 0 to 10, 1 being the slightest pain and 10 being the worst pain of your life. How would you rate your pain??

QUALITY

What does the pain feel like? (Some patients may struggle to explain the character of their pain. If this the case, give them a list of options (e.g. tight, sharp, dull)

Is it present at rest? Does it wake you up in the night?

How is it affecting your daily activities? (DEATH-Dressing/Eating/Ambulate/Toilet/Hygiene)

RADIATION

Does the pain radiate anywhere?

ASSOCIATED SYMPTOMS SYMPTOMS CONDITIONS

Fever, chills (recent infections) Osteomyelitis/ Diskitis/ abscess/ Shingles Nausea/Vomiting Esophagitis Headache Meningitis/ Migraine/ TOS/Occipital neuralgia Fatigue/ heat intolerance Thyroiditis Dizziness/ drop attacks Vertebral artery insufficiency Vision changes/ Photophobia Vertebral artery insufficiency/ Migraine/

occipital neuralgia/ Whiplash injury Painful neck swellings/ difficulty in swallowing Lymphadenitis Stiffness in the neck Meningitis History of sudden jerky movement of neck Whiplash Chest pain/ Shortness of breath Aortic aneurysm/ ACS/ Aortic dissection Chronic cough TB Unintentional Weight loss/ Weight gain Cancer/ TB/ Thyroiditis Weakness/ Numbness & tingling Spinal Cord compression (fracture/ disc

herniation)/ TOS/Cervical stenosis Urinary retention/ incontinence Spinal Cord compression, Cauda eqina

syndrome Early morning stiffness Spondylitis/ Rheumatoid arthritis

Trauma Muscle strain/ ligament sprain/ Fracture/ dislocation

Rash/skin changes Herpes zoster Multiple joint involvement RA/ Multiple Myeloma

Change in Gait Spinal Cord compression Change in bowel habits Cervical stenosis/ Thyroiditis Difficulty in writing/ gripping Cervical Stenosis Mouth ulcers

AGGRAVATING AND ALLEVIATING FACTORS

Does anything make it worse ?

- sneezing/ coughing (Fracture) - worse at night (spondylitis/malignancy) - physical activity (OA/ Fracture/ disk herniation) - exposure to cold

Is there anything that makes it better? - physical activity (Spondylitis/ Rheumatoid arthritis)

PREVIOUS EPISODES

Have u had any such complaints in the past? (if yes ask LIQRAAA) FREQUENCY

How often do you experience it?

How long does each episode last?

Can you describe the worst episode of neck pain you have had?

PAMHUGFOSS WADES PMH Apart from the regular questions ask about the following:

Any heart disease

Diabetes

Hypertension

Stroke

Any lung disease

ALLERGIES Ask regular questions MEDICATIONS Apart from the regular questions ask about the following:

Corticosteroids use HOSPITALIZATION/SURGICAL HISTORY FAMILY HISTORY Apart from the regular questions ask about the following:

degenerative disease/ osteoporosis/ malignancy/ heart & lung disease OBSTETRIC HISTORY Lmp, Cycle- regular/irregular, Flow SEXUAL HISTORY Ask regular questions SOCIAL HISTORY SODA- smoking/occupation/illicit drugs/alcohol WADES- Weight/Appetite/Diet/Exercise/Sleep SUMMARIZE AND ASK IF THE PATIENT HAS ANY OTHER CONCERNS

PHYSICAL EXAMINATION

1. Brief HEENT EXAMINATION (only if patient has any vision changes)

Eyes

Oral cavity

2. FULL BACK EXAMINATION INSPECTION

Spinal deformities

Scars

Swelling/redness

Wasting of muscles (chronic immobility)

Active Range of motion

- Cervical spine : Flexion/extension/lateral flexion/ rotation

Gait (do it at last)

PALPATION

Palpate Spinal process (check for alignment)

Para spinal muscle tenderness

Check for CVA tenderness.

SPECIAL TEST

Chin to chest Test

Ten second test

Lhermitte sign

3. Brief EXTREMITIES EXAMINATION( Upper limb)

INSPECTION

Deformities

Swelling/redness

PALPATION

Tenderness

Strength

Deep tendon reflexes (elbow joint B/L)

Sensation to light touch

Brief CVS and RS EXAMINATION ( ONLY IF PATIENT C/O OF CHEST PAIN/SOB) ASCULTATION

For heart and breath sound auscultate two areas in the chest

CLOSURE Closure is the most important part of your patient encounter where the patient is informed what exactly you are thinking about his concerns and the next steps you want to take to ensure your patient gets the best treatment!

Mention the most appropriate two differential diagnoses in medical terminology and explain it in simple terms to the patient!

Explain about atleast one important test that you will be performing on the patient, like an MRI/ USG/ CT.

Then counsel the patient on smoking/alcohol/diet/exercise/drugs only if he is interested.

Finish it by asking if the patient as any questions for you! Remember nothing should come as a surprise to the patient, it’s the duty of doc to give every possible detail to his patient and the free will to take decisions!

WORKUP Select appropriate ones based on your differential diagnoses

X-RAY C SPINE

MRI C SPINE

LP AND CSF ANALYSIS

DEXA

CA2+ AND VIT D LEVELS

RA FACTOR, ANA

CBC WITH DIFF.

PCR

DFA

T3, T4, TSH

SPUTUM CULTURE

CHEST X-RAY

ESR

CHALLENGING QUESTIONS

1. Doctor do I have a fracture?

2. Do I have a cancer in my head? It feels so heavy

3. Do you think it is because of the soft pillows that I use to sleep on?

4. Can you inject me a pain killer?

5. Doctor do u think it is because of working for long hours at the computer?

6. Doctor can this Herpes spread to my child? I am really worried

7. Can you give me an absence letter for work?

8. Will i be able to lift heavy weights at the gym?

9. My friend suggested me to wear a neck brace. Do you think my condition will improve if I do that?

NOTES

CERVICAL FRACTURE H/o of trauma, point tenderness, swelling and bruising, pain worsens with movement, loss of feeling/ pin prick sensation of arms

CERVICAL STRAIN/SPRAIN Diffuse neck pain, worsens with movement and improves with rest.

DISK HERNIATION Arm pain more than neck pain, worsens with flexion and rotation of neck, pain may radiate to shoulder, arm, hand and fingers.

CERVICAL SPINAL STENOSIS Slow onset, weakness and numbness of hand, weakened hand grip, difficulty in typing/handwriting/buttoning/walking, b/b changes

WHIPLASH INJURY H/o of sudden jerky movement/MVA, headache, dizziness, fatigue, tinnitus, visual disturbance, arm/jaw pain

POSTURAL H/o of extended computer/cell phone use/ prolonged driving. Neck stiffness, back pain, headaches, insomnia, fatigue

MALIGNANCIES Pain worsens in supine position, spinous process tenderness, weight loss, fatigue

INFLAMMATORY SPONDYLOARTHROPATHY Intermittent pain at night, morning pain and stiffness

OSTEOMYLITIES/DISKITIS Constant pain, spinous process tenderness, fever or no fever

AORTIC DISSECTION Tearing pain in chest and back, SOB

THYROIDITIS H/o of viral infection, weight/skin/ b/b changes, fatigue, anxiety, tremors, PLP, insomnia

HERPES ZOSTER Unilateral dermatomal pain, allodynia, vesicular rash

TORTICOLLIS Tilted neck, neck stiffness, thickened sternocleidomastoid muscle, unequal shoulder heights.

CAROTID/VERTEBRAL ARTERY DISSECTION H/o of stroke, unilateral neck pain /headache, face pain, double vision, droopy eyelids, weakness, decrease in taste sensation, whooshing sound in the ears

FIBROMYALGIA Neck/back/abd pain, fatigue, muscle tenderness, anxiety, insomnia, loss of concentration, GI disturbances.

THORACIC OUTLET SYNDROME Athletes, shoulder/arm/chest pain, pain increases when arm is raised, numbness and tingling in arms, weakening grip, hand discolouration, cold hands.

OCCIPITAL NEURALGIA Pain near base of skull, radiated to back/scalp/eye, neck movements trigger the pain, scalp tender to touch, photophobia

CAUDA EQUINA SYNDROME Low back pain, motor weakness/sensory loss in one or both legs, bowel/bladder dysfunction, sexual dysfunction.

Any Suggestion/doubts: Contact: Dr Pradeep Balu Whatsapp/IMO: +919741603068 Facebook id: https://www.facebook.com/drpradeepbalu Instagram: https://www.instagram.com/balu.pradeep/ Telegram id: drpradeepbalu