Neck Pain Nachii Narasinghan
Introduction • F>M • Highest prevalence in middle age • Types • Non-specific • Whiplash • Cervical spondylosis • Acute torticollis
Assessing neck pain • Exclude non-MSK causes • Assess for red flags • Assess range of neck movements • Perform a neuro exam • Identify risk factors for developing neck pain • Identify psychosocial factors that may suggest increased risk for chronicity and disability
The negative predictive value of these ‘red flags’ clinical findings is high; • if no ‘red flags’ are present, then it is unlikely that a serious spinal abnormality has been missed. • Individual positive findings must be interpreted with care, as their positive predictive value for diagnosing serious disease is poor (Williams and Hoving, 2004)
Red Flags • 'Red flags' that suggest cancer, infection, or inflammation: • Malaise, fever, unexplained weight loss. • Pain that is increasing, is unremitting, or disturbs sleep. • History of inflammatory arthritis, cancer, tuberculosis, immunosuppression, drug abuse, AIDS, or other infection. • Lymphadenopathy. • Exquisite localized tenderness over a vertebral body. • 'Red flags' that suggest severe trauma or skeletal injury: • A history of violent trauma (e.g. a road traffic accident) or a fall from a height. However, minor trauma may fracture the spine in people with osteoporosis. • A history of neck surgery. • Risk factors for osteoporosis: premature menopause, use of systemic steroids.
'Red flags' that suggest vascular insufficiency: • Dizziness and blackouts (restriction of vertebral artery) on movement, especially extension of the neck when gazing upwards. • Drop attacks. • 'Red flags' that suggest compression of the spinal cord (myelopathy): • Insidious progression. • Neurological symptoms • gait disturbance, clumsy or weak hands, or loss of sexual, bladder, or bowel function. • Neurological signs: • Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs. • UMN signs in the lower limbs (Babinski's sign — up-going plantar reflex, hyperreflexia, clonus, spasticity). • LMN signs in the upper limbs (atrophy, hyporeflexia). • Sensory changes are variable, with loss of vibration and joint position sense more evident in the hands than in the feet.
Investigations • Cervical x-rays and other imaging are not routinely required in the dx or assessment of neck pain with radiculopathy or non-specific neck pain. • Best to be open about limitations of investigations and reassure patients that they can be helped without such investigations.
What should be done with patients with neck pain? (x-ray shows cervical spondylosis) • Degenerative changes affecting C-spine discs and facet joints • Depends on clinical picture
Abnormal neurology, or persistent or progressive brachialgia with or without abnormal neurology, warrants neurosurgical investigation • Surgery is good at reducing compressive nerve root symptoms and signs and arresting myelopathic progression. • Surgery is less good at reducing myelopathic symptoms and signs when these are chronic • Urgency of referral depends on the severity of neurological deficit and rate of progression.
Basis for recommendation • In the absence of ‘red flags’ plain X-rays of the cervical spine are unlikely to help and may lead to false-positive findings (Williams and Hoving). • Features of degenerative disease are also common in asymptomatic people older than 30 years of age and correlate poorly with clinical symptoms. (Binder,2007).
Neck pain • Acute (3-4 weeks) • Sub-acute (4-12 weeks) • Chronic
Acute neck pain • Encourage the patient to: • remain as active as possible • restore their neck movements as pain allows • correct poor posture if precipitating or aggravating the neck pain • sleep with one pillow which provides lateral • support and also gives support to the hollow of the neck. Two pillows may force the head into an unnatural position.
Discourage the patient from: • prolonged absence from work • wearing a cervical collar (which may hinder recovery).
Sub acute neck pain • Refer to physiotherapy for a multimodal treatment • strategy that includes postural advice, exercises and manual therapy. • Acupuncture may be included at this stage. • Promote positive attitudes to activity and work. • Address any psychosocial factors • Consider referral to a psychologist or occupational health clinician.
Chronic neck pain • Continue physiotherapy if it is helping, discontinue if not. • Avoid passive interventions, e.g. electrotherapy and massage. • Reassess psychological factors. • Consider referral to a pain clinic for people with chronic pain or nerve root symptoms where there is poor control.
Take home messages • Be aware of red flags in the assessment of neck pain. • Mainstay of the initial management of simple neck pain is conservative and in primary care. • Role of imaging is limited.