Approach to neck pain

Question 1

Learning Outcome:

Answer 1

1. Mechanical
   - Torticollis
   - Klipper-Feil Syndrome
   - Prolase intervertebral disc
   - Cervical spondylosis
   - Cervical myelopathy/Stenosis
2. Infection
   - Pyogenic infection
   - Tuberculosis
3. Inflammatory
   - Rheumatoid Arthritis
   - Ankylosing Spondylitis

Question 2

Torticollis pathology

Answer 2

1. Definition: Chin is slightly twisted upwards, towards one side
2. Etiology:
   i. Congenital/Infantile
   - sternocleidomastoid fibrous, fails to elongate due to ischemia from abnormal delivery or position in utero
   ii. Acquired/Secondary /Childhood
   - congenital bone anomaly
   - infection (lymphadenitis, retropharyngeal abscess, tb)
   - trauma
   - juvenille RA
   - posterior fossa tumour

Question 3

Infantile Torticollis diagnosis

Answer 3

Hx

• lump in first few weeks of life
• breech delivery, hip dysplasia, difficult labour
• torticollis appear around 1-2 years old
• limitation of neck movement

Pe

• torticollis: chin elevated, rotated to one side, ear apprach shoulder
• plagiocephaly (assymmetrical face)
• sternocleidomastoid hard, tight

Question 4

Prolapse Intervertebral Disc Pathology

Answer 4

1.Epidemiology: Less common than lumbar

2. Pathology: similar to lumbar
   - commonly C6, C7
3. Etiology: Precipated by local strain or injury, sudden flexion and rotation or whiplash injury

Question 8

Prolapse intervertebral disc diagnosis

Answer 8

Hx

1. Neck pain
   - increase with couging, straining
   - radiate to scapula, occiput
   - radiate to outer elbow, back of wrist, index, middle finger
   - associate with: paraesthesia, stiffness

Pe

• Wry neck (muscle spasm)
• +ve spurling’s test
• abduction relief sign
• restricted ROM
• TRO Upper limb neurological deficits

X-ray

• loss of cervical lordosis
• narrowing of disc space

Question 9

Cervical Spondylosis pathology

Answer 9

1. Definition: chronic degenerative disc
2. Epidemiology: most common at C5/6, C6/7. Age over 40 years old
3. Pathology:
   - disc degenerates, flatten, less elastic
   - facets joints become arthritic
   - bony spurs, ridges at anterior and posterior margin of vertebral body
   - may irritate dura in spinal canal (myelopathy)
   - may also cause narrowing of vertebral foramina (radiculopathy) due to osteophytes

Question 10

Cervical Spondylosis diagnosis

Answer 10

Hx

1. Neck pain
   - gradual, intermittent pain
   - morning stiffness
   - radiate to occipit, back of shoulder or arm
   - associated with: paraesthesia, weakness, clumsiness, limited neck movement due to pain

Pe

• tenders muscle back of neck, scapulae
• +/- sensory loss, weakness, depressed reflex (radiculopathy)

X-ray

• loss of cervical lordosis
• narrowing of disc space
• spurs formation at anterior and posterior margin of vertebral margin (osteophytes)

Question 11

Cervical Spondylosis management

Answer 11

1. Conservative
   - analgesics
   - heat, massage (physio is mainstay: intermittent traction and passive manipulation)
   - cervical collar (restrict movement reduce pain)
2. Operative
   - indication: neurological sx, signs, failure of conservative tx (pain do not resolve, disturb daily activity)
   - how;
   i. Anterior discectomy and fusion
   ii. Foraminotomy
   iii. Disc replacement
3. DDX:
   - Nerve entrapment syndromes
   - rotator cuff lesion
   - cervical tumors
   - thoracic outlet syndrome

Question 12

Spinal Stenosis with Myelopathy pathology

Answer 12

1. Cause of stenosis and myelopathy:
   - PID
   - Posterior bone spurs (Spondylosis)
   - Osteoarthritis of facet joints
   - Thickening of ligamentum flavum
   - Ossification of PLL
   - Vertebral displacement
2. Pathology of myelopathy:
   - cord compression
   - ischemia due to impaired venous drainage, arterial flow
3. DDX for myelopathy:
   - multiple sclerosis
   - ALS
   - syringomyelia
   - spinal cord tumors

Question 13

Spinal Stenosis with Myelopathy diagnosis

Answer 13

Hx

• many asymptomatic: no myelopathy
• symptomatic:
  i. neck pain
• increase with neck extension
  ii. radiculopathy pain
  iii. associated with:
• paraesthesia
• weakness (progressive, longstanding)
• numbness
• clumsiness
  iv. UMNL: leg spasm, clonus

Pe:

• LMNL in upper limb
• UMNL in lower limb

X-Ray

• Lateral: AP spinal canal diameter (posterior vertebrae to base of spinous process) < 11mm
• Pavlov ratio (AP diameter canal: vertebral dia,eter) less than 0.8

Question 14

Rheumatoid Arthritis pathology

Answer 14

1. Epidemiology: 30% of patient with RA
2. Pathology:
   - erosion of atlantoaxial joint, transverse ligament
   - cranial sinkage (odontoid peg into foramen magnum’)
   - erosion of facet joints (nerve root entrapement?)
   - vertebral osteoporosis

Question 15

Rheumatoid Arthritis diagnosis

Answer 15

Hx

• neck pain
• restricted neck movement
• radiculopathy

Pe
- Lhermitte’s sign +ve (flexion of the neck cause electric sensation down the spine)

X-ray

• atlanto-axial instability
• atlanto-occipital erosison

Question 16

Ankylosing Spondylitis pathology

Answer 16

1. Epidemiology: most common seronegative spondyloarthropathy
2. Pathology:
   - bone is osteoporotic, prone to fracture
3. CF
   - Neck pain, stiffness, kyphotic
   - chin on chest deformity, unable to extend neck to see ten paces ahead