Approach to Cervical Spine Complaint Flashcards
Neck pain is the #__ cause of disability in the US
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Red Flags of Neck Pain
- recent trauma
- neurologic sxs (ex. weakness, gait difficulty, bladder dysfunction)
- shock-like paresthesia with neck flexion
- fever or chills
- Hx of injection drug use
- Immunosuppression
- Chronic glucocorticoid use
- unexplained weight loss
- Hx of cancer
- HA, shoulder ache, hip girdle pain
- anterior neck pain
Special tests for Cervical Radiculopathy
- Spurlings Test
- Manual Distraction Test
Special Tests for Meningeal Irritation
- Kernigs Sign
- Brudzinskis Sign (nuchal rigidity)
Special Tests for Thoracic Outlet
- Roos Test
- Adsons Test
- East Test
Causes of neck splinting or stiffness:
- c-spine fxs
- cord injuries
- ligamentous injuries
- muscle strains
- muscle spasm
- SAH
- meningitis
Contraindications to HVLA
- Rheumatoid Arthritis: weak odontoid ligament is susceptible to rupture
- Downs Syndrome: weak odontoid ligament susceptible to rupture, may have incomplete or missing odontoid process
- Carotid Disease or PVD
- Osteoporosis
- Local metastases
- Patients on anticoagulants: sheer stress –> intracranial bleed
- Osseous or ligamentous disruption
Traumatic Neck Pain Differential
- Myofascial injury (muscle strains, whiplash, etc)
- Cervical fx
- Ligamentous injury
- Disc injury
- Cord or nerve root injury
- Spinal cord injury w/o radiographic abnormality (SCIWORA)
SCIWORA
- patient has normal plain films and normal CT of cervical spine but continues to have neurologic signs or sxs
- must keep spine immobilized until MRI and evaluation/consultation with neurosurgeon
- more common in kids and elderly
Atraumatic Intrinsic Neck Pain
within the neck
- MSK (majority of atraumatic neck pain; includes cervical spondylosis, degenerative changes)
- Neurologic (radiculopathy, myelopathy)
Atraumatic Extrinsic Neck Pain
outside the neck
- systemic disease
- neurologic conditions
- referred pain
- thoracic outlet syndrome
Examples of Atraumatic Extrinsic Neck Pain
- thoracic outlet syndrome
- coronary artery disease
- metastatic disease
- neurological conditions
- referred shoulder pain
- rheumatologic conditions
- fibromyalgia
- visceral etiologies
- infection (meningitis)
Torticollis
“twisted neck”
Congenital Torticollis
usually arises from muscular fibrosis of the SCM muscle and less commonly from neurologic or bony abnormalities
Adult Torticollis
- acquired
- typically results from SCM or trapezius muscle injury or inflammation
- wide variety of conditions can also cause this due to cervical muscle spasm or cervical nerve irritation
Life-threatening causes of Torticollis:
- retropharyngeal abscess
- C-spine injury
- CNS tumor
- spinal epidural hematoma
What is the most common cause of acute and chronic neck pain in adults?
Cervical Spondylosis
Cervical Myelopathy
- any neurological deficit related to the spinal cord
- signs and sxs: weakness, numbness, clumsy hands, gait disturbances, sexual dysfunction, bowel or bladder dysfunction, sxs cross multiple dermatomes
- associated with UMN findings (muscle spasticity, hyperreflexia, increased muscle tension)
- needs emergent MRI
Cervical Radiculopathy
- any neurological deficit occurring at or near the nerve root
- signs and sxs: sharp, burning pain radiating to the trapezius, periscapular area or down the arm; weakness or paresthesias may develop weeks after onset; radiation is dermatomal
- C5-C6 followed by C6-C7 are the most common
- needs urgent workup, non-emergent MRI, NSAIDS, OMM, PT
Meningitis
- signs and sxs: fever, malaise, HA, photophobia, neck pain and stiffness, AMS, rash, meningismus
- caused by bacteria (Hemophilus, strep, pneumonia), neiserria menigitidis, viral
How is meningitis diagnosed?
Lumbar Puncture
Thoracic Outlet
- confined space between the clavicle and first rib
- structure located here: nerves of brachial plexus, subclavian artery and vein
Thoracic Outlet Syndrome
Compression of the neurovascular bundle by various structures in the area just above the first rib and behind the clavicle, within the confined region of the thoracic outlet
Symptoms of Thoracic Outlet Syndrome
- arm pain
- arm numbness
- arm weakness
- reproducibly aggravated by any activity that requires elevation or sustained use of the arms or hands above the head
Do most patients with atraumatic neck pain require imagining?
No, not if there aren’t any red flags
Patients with atraumatic neck pain that should be imaged:
- progressive neurological findings
- moderate to severe neck pain (affects sleep, daily activity, occupation)
- do not respond to conservative management over six weeks
What test is used for Cervical Myelopathy?
Hoffmann Reflex
Hoffmann Reflex
- Indicates: UMN damage due to cervical cord compression, stroke, encephalitis, etc
- Steps: physician quickly releases distal middle finger from extension
- (+) Test = involuntary flexion of the terminal phalanx of the thumb and the 2nd and 3rd phalanx of some other finger
What tests are used for Cervical Radiculopathy?
- Neck Compression Test
- Neck Distraction Test
- Spurling Test
