Approach To Cervical Spine Complaint

Question 1

What are atraumatic causes of neck pain?

Answer 1

Musculoskeletal, neurologic (radiculopathy or myelopathy) or non-spinal (systemic disease or referred pain)

Question 2

What are some causes for traumatic neck pain?

Answer 2

Myofascial injury (strain, whiplash, etc), cervical fracture, ligamentous injury, disc injury, cord or nerve root injury, SCIWORA (SC injury without radiographic abnormality)

Question 3

Describe myofascial neck pain

Answer 3

Very common
May or may not be traumatic
Sx: pain, spasm, loss of ROM in the neck, occipital HA
Pain can be persistent with little identifiable abnormality seen on imaging
Ex: whiplash, muscle strain, etc

Question 4

Describe cervical fractures

Answer 4

Most are stable
All require neuro consultation
Must determine if stable or unstable (done with imaging)
Document any neuro complaint in the history and initial presence + level of sensory and motor loss, rectal tone during PE

Question 5

Describe SCIWORA

Answer 5

Need a high degree of suspicion to dx
Pt has normal plain fils and normal CT of C spine but continues to have neuro signs and sx
Must keep spine immobilized until MRI and evaluation/consultation with a neurosurgeon
More common in kids (more flexible neck with large head) and elderly

Question 6

What accounts for the vast majority of atraumatic neck pain?

Answer 6

Musculoskeletal

Ex. Cervical spondylosis (degenerative changes)

Question 7

What is an example of a non spinal cause of atraumatic neck pain?

Answer 7

Thoracic outlet syndrome

Question 8

What is congenital torticollis?

Answer 8

Arises from muscular fibrosis of the SCM and less commonly from neuro or bony abnormalities

Question 9

What are the classifications for torticollis?

Answer 9

Congenital, adult and life threatening causes of torticollis

Question 10

What are life threatening causes of torticollis?

Answer 10

Retropharyngeal abscess, C spine injury, CNS tumor

Spinal epidural hematoma

Question 11

Describe cervical spondylosis

Answer 11

Most common cause of acute and chronic neck pain in adults
Often asymptomatic
Can cause general neck pain, radiculopathy, myelopathy
Incidence increases with age

Question 12

What is cervical myelopathy?*

Answer 12

Any neurologic deficit related to the SC
Signs and sx: bilateral or distal sx (weakness/numbness), may complain of clumsy hands, gait disturbances, sexual dysfunction, bowel or bladder dysfunction
Needs emergent MRI

Question 13

What is cervical radiculopathy?*

Answer 13

Any neurologic deficit occurring at or near the nerve root
Signs and sx: sharp, burning pain radiating to the trapezius, periscapular area or down the arm; weakness or paresthesia may develop weeks after pain onset
C5-6 followed by C6-7 are the most common
Urgent work up, non-emergent MRI, NSAIDs, OMM, PT

Question 14

Describe meningitis

Answer 14

Sx: fever, malaise, HA, photophobia, neck pain and stiffness, AMS, rash (petechiae and purpura) and meningismus
Nuchal rigidity, Kernig’s and Brudzinski’s sign of meningeal inflammation
Causes: bacterial, neisseria meningitidis (gram neg dipplocci), viral, other
Diagnosed by lumbar puncture*

Question 15

Describe thoracic outlet syndrome

Answer 15

The thoracic outlet is a confined space between the clavicle and 1st rib*
Compression of the neurovascular bundle by various structures in the area above the 1st rib and behind the clavicle
Sx: arm pain, numbness and weakness (reproduced by activity that requires elevation or sustained use of the arms above the head)
Roo’s/EAST test

Question 16

Most patients with atraumatic neck pain without red flags do not require what?

Answer 16

Imaging

Question 17

Describe a focused ROS for neck pain

Answer 17

Recent major neck trauma
Neuro sx or sings that suggest spinal cord issue (weakness, gait difficulty, bowel or bladder dysfunction)
Shock like paresthesia (Lhermitte’s phenomena) with neck flexion

Question 18

What discriminators and life threats should be evaluated?

Answer 18

Fever, chills, CP, SOA, history of recent trauma

Question 19

What are red flags for pts with neck pain?

Answer 19

Recent major neck trauma, neuro sx that suggest SC issue, shock like paresthesia with neck flexion, fever or chills, hx of injection drug use, immunosuppression, chronic steroid use, unexplained weight loss, history of cancer, HA shoulder or hip pain, visual sx in older patient, anterior neck pain

Question 20

Do not check ROM on patients with traumatic neck pain unless they have what?

Answer 20

Been cleared radiographically or clinically by Nexus criteria

Question 21

What are the special tests for cervical radiculopathy?

Answer 21

Spurling’s test

Manual distraction test

Question 22

What special tests are used for meningeal irritation?

Answer 22

Kernig’s sign

Brudzinski’s sign

Question 23

What specialty tests are used for thoracic outlet syndrome?

Answer 23

Roo’s or east test

Question 24

Neck stiffness (inability or unwillingness) to move the neck is what?

Answer 24

Concerning

Causes include C spine fractures, cord injuries, ligamentous injury, muscle strains, muscle spasm, SAH and meningitis

Question 25

What are the contraindications for HVLA?

Answer 25

RA and Down syndrome (weak or missing odontoid ligament)

Carotid disease, PVD, osteoporosis, local cancer, pts on anticoagulants, osseous or ligamentous disruption