Approach to Cervical Spine Complaint

Question 1

What percent of the adult general population has neck pain at any time?

Answer 1

10-20%

Question 2

What are the causes of neck pain?

Answer 2

Traumatic or atraumatic (MSK, radiculopathy, myelopathy, or systemic disease or referred pain)

Question 3

For traumatic neck pain, what diagnoses should you consider?

Answer 3

Myofascial injury, cervical fracture, ligamentous injury, disc injury, cord or nerve root injury

Question 4

What are the symptoms of myofascial neck pain?

Answer 4

Pain, spasm, loss of ROM, occipital headache

Question 5

How do you determine if a neck fracture is stable or unstable?

Answer 5

CT or MRI with a radiological and neurosurgical consultation

Question 6

What is a SCIWORA?

Answer 6

Spinal Cord Injury without Radiographic Abnormality; patient has normal plain films and normal CT but with neurological signs or symptoms; must keep spine immobilized until MRI and evaluation/consultation with a neurosurgeon

Question 7

What are the nexus criteria?

Answer 7

Used to determine which patients presenting with neck pain after trauma need radiographic imaging

Criteria: absence of posterior midline cervical tenderness, normal level of alertness, no evidence of intoxication, no abnormal neurologic findings, no painful distracting injuries

If all criteria are met, patient doesn’t need imaging; if all are not met, apply cervical collar and image patient

Question 8

What makes up the majority of atraumatic neck pain?

Answer 8

MSK

Question 9

What are some diagnoses of atraumatic neck pain with non-spinal causes?

Answer 9

Coronary artery disease, malignancy, neurologic conditions, referred shoulder pain, rheumatic conditions, fibromyalgia, thoracic outlet, visceral etiologies, infection (meningitis)

Question 10

What is spondylosis?

Answer 10

Degenerative discs and osteophytes; most common cause of acute and chronic pain in adults; incidence increases with age and is often asymptomatic

Question 11

What is cervical myelopathy? What are the signs and symptoms?

Answer 11

Any neurologic deficit related to the spinal cord

Signs/SX: bilateral or distal weakness/numbness, clumsy hands, gait disturbances, sexual dysfunction, bowel/bladder dysfunction

Needs emergent MRI

Question 12

What is cervical radiculopathy? What are the signs and symptoms?

Answer 12

Any neurologic deficit occurring at or near the nerve root

Signs/SX: sharp, burning pain radiating to the traps, periscapular area or down the arm, weakness or paresthesia may develop weeks after pain onset

C5-C6 followed by C6-C7 are most common; urgent workup, non-emergent MRI, NSAIDS, OMM, PT

Question 13

What are the signs and symptoms of meningitis?

Answer 13

Fever, malaise, headache, photophobia, neck pain and stiffness, AMS, rash, meningismus

Nuchal rigidity, Kernig’s and Brudzinski’s signs of meningeal inflammation

Question 14

What are the causes of meningitis?

Answer 14

Bacterial: hemophilus, strep, pneumonia

Neiserria menigitidis (gram negative dipplococci) is now less prevalent since the vaccine; can also be viral

Question 15

How do you diagnose meningitis?

Answer 15

Lumbar puncture; treatment depends on etiology

Question 16

What is thoracic outlet syndrome?

Answer 16

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

Question 17

What are the symptoms of thoracic outlet syndrome?

Answer 17

SX: arm pain, numbness, weakness; reproducibly aggravated by any activity that requires elevation or sustained use of the arms or hands above the head

Question 18

When should patients with atraumatic neck pain be sent for imaging?

Answer 18

Progressive neurological findings, moderate to severe neck pain affecting sleep, daily activities, occupation; those who do not respond to conservative management over 6 weeks

Question 19

What are some red flags in patients with neck pain?

Answer 19

Recent major neck trauma, neurologic symptoms or signs that suggest spinal cord issue, shock-like paresthesia with neck flexion, fever or chills, history of injection use, immunosuppression, chronic glucocorticoid use, unexplained weight loss, history of cancer, headache, anterior neck pain

Question 20

What structures are you palpating for when palpating the neck?

Answer 20

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

Question 21

For the vascular portion of the neck exam, what are you feeling for?

Answer 21

Carotid pulse and jugular venous distention

Question 22

For cervical radiculopathy, what special tests should you do?

Answer 22

Spurling’s or manual distraction

Question 23

For meningeal irritation, what special tests should you do?

Answer 23

Kernig’s sign or Brudzinski’s sign

Question 24

For thoracic outlet syndrome, what special tests should you do?

Answer 24

Roo’s or EAST test

Question 25

In terms of ROM of the neck, what are some things to keep in mind?

Answer 25

1) Never check ROM in a trauma patient unless they have been cleared of cervical fracture/spinal cord injury clinically or radiographically
2) Never force ROM; be cautious when performing spurling maneuver
3) Neck stiffness (inability or unwillingness) to move the neck is concerning

Question 26

What are some causes of neck splinting or stiffness?

Answer 26

C-spine fractures, cord injuries, ligamentous injuries, muscle strains, muscle spasms, meningitis

Question 27

What are some contraindications for using HVLA (high velocity low amplitude)?

Answer 27

Rheumatoid arthritis, down syndrome, carotid disease, osteoporosis, local metastases, patients on anticoagulants, osseous or ligamentous disruption