2a. Approach to Cervical Complaint

Question 1

4 cause of disability in the US

10-20% of adult general population has this at any given time

Answer 1

neck pain

Question 2

atraumatic causes of neck pain

Answer 2

• musculoskeletal (most common)
• neurologic
• non-spinal causes

Question 3

broad based differential for traumatic neck pain

Answer 3

• myofascial injury
• cervical fracture
• ligamentous injury
• disc injury
• cord or nerve root inury
• SCIWORA

Question 4

pain, spasm, loss of neck ROM, occipital headache

persist with little abnormality on MRI, CT, radiograh, or bone scan imaging

may or may not be traumatic

ex: whiplash, muscle strain, etc.

Answer 4

myofascial neck pain

Question 5

occur in 3% of blunt trauma

most stable

all require neurosx consult

determine if stable or unstable via imaging or consultation

document: initial presence, leel of sensory/motor, rectal tone

Answer 5

cervical fractures

Question 6

What would you document in patients presenting with possible cervical fracture?

Answer 6

• initial presence
• initial level of sensory/motor loss
• rectal tone

Question 7

SCIWORA

Answer 7

spinal cord injury without radiographic abnormality

Question 8

What should you do with patients presenting with SCIWORA?

Answer 8

If patienthas normal plain films and cervical CT but continues to have neurologic signs/symptoms, must keep spine immobilized until MRI and evaluation/consult with a neurosurgeon.

Question 9

Nexus criteria

Answer 9

• absence of posterior midline C-spine tenderness
• normal level of alertness
• no intoxication
• no abnormal neurologic findings
• no painful distracting injuries

Question 10

When is Nexus criteria used?

Answer 10

patient presents with neck pain after trauma

Question 11

What happens if patient has (+) Nexus?

Answer 11

1. Apply C-collar
2. Obtain imaging

Question 12

most common cause of musculoskeletal atraumatic neck pain

Answer 12

cervical spondylosis (degenerative changes)

Question 13

musculoskeletal atraumatic neck pain

Answer 13

• cervical spondylosis
• discogenic pain
• myofascial spain
• whiplash
• torticollis
• facet osteoarthritis

Question 14

neurologic atraumatic neck pain

Answer 14

radiculoapthy and/or myelopathy

Question 15

non-spinal causes musculoskeletal atraumatic neck pain

Answer 15

Question 16

most common cause of acute and chronic neck pain in adults

degeneraive changes in spine: degenerative discs and osteophytes

incidence increases with age

often asymptomatic

causes general neck pain, radiculopathy, and myelopathy

Answer 16

cervical spondylosis (degenerative changes)

Question 17

cervical myelopathy vs. cervical radiculopathy

Answer 17

cervical myelopathy: neurologic deficit related to SC

cervical radicuopathy: neurologic deficit at or near nerve root

Question 18

symptoms of cervical myelopathy

Answer 18

bilateral or distal symptoms (weakness/numbness)

clumsy hands

gait disturbances

sexual dysfunction

bowel/bladder dysfunction

Question 19

symptoms of cervical radiculopathy

Answer 19

sharp, burning pain radiating to the trapezius, periscapular area, down the arm

weakness or paresthesias may develop weeks after pain onset

most common at C5-C6 followed by C6-C7

Question 20

Is cervical myelopathy or radiculopathy more emergent?

Answer 20

Cervical myelopathy requires emergent MRI.

Cervical radiculopathy requires urgent work-up.

Question 21

symptoms/signs of meningitis

Answer 21

fever, malaise, headache, photophobia, neck pain/stiffness, AMS, rash (petechiae and purpura), and meningismus

Question 22

tests for meningitis

Answer 22

• nuchal rigidity
• Kernig’s
• Brudzinski’s

Question 23

When would you likely see a rash with meningitis?

Answer 23

Neisseria meningitidis

(has been less prevalent since vaccine; Gram neg dipplococci)

Question 24

How do you diagnose meningitis?

Answer 24

perofrm a lumbar puncture

Question 25

bacterial causes of meningitis

Answer 25

hemophilus, strep pneumonia, and neisseria menigitidis

Question 26

compression of NV bundle by various structures in the area just above first rib and behind the clavicle, within the confined space of the thoracic outlet

Answer 26

**thoracic outlet syndrome**

Question 27

symptoms of **thoracic outlet yndrome**

Answer 27

arm pain, numbness, and weakness reproducibly aggravated by any activity requiring elevation or sustained use of arms or hands above the head

Question 28

What is more common: vasculogenic or neurogenic TOS?

Answer 28

**neurogenic (95%)** vascular: arterial or venous (5%)

Question 29

tests for **thoracic outlet syndrome**

Answer 29

* Roo's EAST test * Adson's test

Question 30

When would you consider imaging work-up for patients with atraumatic neck pain?

Answer 30

patients with progressive neurologic findings and moderate-to-severe neck pain who do not respond to conservative management for \>6 weeks ## Footnote **most patients with atraumatic neck pain w/o red flags _do not_ require imaging**

Question 31

clinical significance of **major neck trauma**

Answer 31

concern for **C-spine fracture**

Question 32

clinical significance of **neurologic symptoms/signs such as weakness, gait difficulty, bowel/bladder dysfunction**

Answer 32

concern for **cervical cord compression**

Question 33

clinical significance of **shock-like paresthesia (Lhermitte's phenomenon) w/ neck flexion**

Answer 33

suggestive of **cervical cord compression or MS**

Question 34

clinical significance of **fever or chills with neck pain**

Answer 34

suggestive of **infection**

Question 35

clinical significance of **history of injection drug use**

Answer 35

raises concern for **C-spine or disc infection**

Question 36

clinical significance of **immunosuppression**

Answer 36

raises concern for **infection**

Question 37

clinical significance of **chronic glucocorticoid use**

Answer 37

concern for **infection** or **C-spine compression fracture**

Question 38

clinical significnce of **unexplained weight loss**

Answer 38

suggestive of **malignancy**

Question 39

clinical significance of **history of cancer with neck pain**

Answer 39

raises concern for **mestastatic disease to cervical spine**

Question 40

clinical significance of **headache, shoulder/hip girdle pain, or visual symptoms in older patients** with neck pain

Answer 40

suggestive of **rheumatic disease** (polymyalgia rheumatica, giant cell arteritis)

Question 41

clinical significance of **anterior neck pain**

Answer 41

suggestive of **non-spinal cause (e.g. angina pectoris)**

Question 42

important structures to palpate in the neck

Answer 42

lymph nodes thyroid gland muscle bone connective tissues soft tissues spinous processes disc spaces

Question 43

dermatome of lateral neck

Answer 43

C4

Question 44

dermatome of lateral upper arm

Answer 44

C5

Question 45

dermatome of lateral forearm and thumb

Answer 45

C6

Question 46

dermatome of middle finger

Answer 46

C7

Question 47

dermatome of medial wrist/forearm

Answer 47

C8

Question 48

dermatome of medial elbow/upper arm

Answer 48

T1

Question 49

specialty testing for cervical radiculopathy

Answer 49

* Spurling's test * manual distraction test

Question 50

When would you check ROM in a trauma patient?

Answer 50

**Never** check ROM in a trauma patient **unless** they have been cleared of cervical fracure and/or SC injury clinically or radiographically

Question 51

Why is "neck stifness" (inability or unwillingness) to move the neck concerning?

Answer 51

causes of splinting or stiffness include: C-spine fx, cord injuries, ligament injuries, muscle stains, muscle spasm, SAH, meningitis

Question 52

contraindications for HVLA

Answer 52