1. Neck Pain Dzung H. Dinh, MD, MBA Professor of Neurosurgery University of Illinois College of Medicine at Peoria

2. Disclosure Aesculap ROI Nuvasive

3. Content1. Anatomy2. Evaluation of neck pain3. Differential diagnosis4. Treatment plan

4. Anatomy

5. Anatomy

6. Anatomy

7. Anatomy

8. Anatomy

9. Anatomy

10. Evaluation History Ask the right questions Listen to the patient Formulate a diagnosis Examination To confirm your diagnosis, not to make diagnosis Ordering additional tests Again, to confirm or r/o diagnosis.

13. HistoryAsk the right questions • Critical questions • 1. Pain location • Central/Axial/Paraspinal • Refer HA or Arm Sx • True Radicular • 2. Pain quality • Dull ache • Sharp shooting –neck, occiput, arm • Burning vs. dysesthesia • 3. Pain Pattern - Diffuse Discrete • 4. Numbness – pattern, location • 5. Deficit – pattern/distribution • Not so critical questions • 1. Pain onset/inciting event • 2. Pain provocation • 3. Pain diminution • 4. Up-to-date Rx

14. HistoryListen to the patient • Stumbling gait • Dropping things • Hand falling asleep • Skin feels burnt • Trouble going upstair • Urinary hesitancy • No pain • Woke up with weakness • Slowly getting worse

15. HistoryDiagnosis formulation • Diffuse neck pain, HA, skin burning, TP – myofascial pain. • Discrete arm pain, not much neck pain, discrete deficit – radiculopathy • Weakness, no pain, no numbness – ALS • Hand numbness in median or ulnar pattern- CTS or cubbital Sx • Wrist extensor weakness- C7 or radial nerve • Radicular sx and entrapment sx - Double crush syndrome (C5 or 6 and CTS, C8 or T1 and ulnar)

16. Examinationto confirm your diagnosis • Myofascial pain: Trigger points (supraspinatus, rhomboid, teres), no deficit • Myelopathy: spastic gait, hyperreflexia, path reflex • Radicular distribution deficit – radicular • C5: deltoid, infra/supraspinatus • C6: bicep, dorsal forarm, thumb, index finger • C7: tricep, index, middle finger, finger, wrist extension • C8: 4th,5th fingers, volar of forearm, grip weakness • T1: under arm, finger extension. • Peripheral entrapment • CTS: middle 3 fingers, grip weakness, + Phalen • Cubittal Sx: last 2 fingers, opponens, + Tinel • Radial nerve pathology

17. Additional Teststo confirm your diagnosis • Myofascial pain- EMG/NCV if there is lots of refer Sx • Myelopathy: MRI • Radicular – MRI • Peripheral entrapment – EMG/NCV

18. Treatment Plan Myelopathy with cord compression – surgery Radiculopathy with deficit – surgery +/- Myofascial Pain – Never surgery Peripheral Entrapment Sx - Maybe Double crush Sx – Depends Radiculopathy and Myofascial Pain - depends

19. Case Presentation

22. Thank You