Differential Diagnosis of Neck Pain Flashcards
What are some etiologies of neck pain?
Congenital Disorders Trauma Mechanical Abnormalities Toxicity Metabolic Disorders Inflammatory States Degenerative & Acquired Spinal Diseases Infections
What are some more etiologies of neck pain?
Temporomandibular Joint Dysfunction Thoracic Outlet Syndrome Neoplasms Circulatory Disorders Neurologic Disorders Referred Pain Iatrogenic Psychoneuroses
What is the “job one” in neck pain diagnosis?
Rule Out Any Life, Limb, Organ , and Function Threatening Conditions
During diagnosis, what demographics make you worry?
Age Less Than 20 years Age Over 50 years
During diagnosis, what vital signs make you worry?
Fever Hypertension
During diagnosis, what type of medical history makes you worry?
Trauma Fever Abrupt Onset Neurologic Symptoms (Radicular Pain, Muscle Weakness, Muscle Cramps, Decreased Sensation)
During diagnosis, what findings in the pt’s physical make you worry?
RROM severely restricted (<1/2 the normal range), Radicular symptoms provoked by ROM, Signs of Inflammation, Neurologic Deficits
Major Category: Congenital Disorders
Condition Present Since Childhood, Onset of Symptoms often Insidious, and Symptoms may appear At Any Age, but usually in the late teens to mid-thirties
Major Category: Trauma
Any history of trauma
Major Category: Mechanical
Insidious Onset
Major Category: Toxins
Exposure to toxins: Vocational, Avocational, Incidental
Major Category: Metabolic Disorders
Endocrine: DM, Thyroid disease. Nutrition: Ingestion, digestion, excretion
Major Category: Inflammatory
Abrupt onset: Redness, tumor, fever and pain.
Major Category: Degenerative
Age 50 and older, need imaging
Major Category: Infectious
Fever, WBC elevated, need imaging
Major Category: Neoplasm
Age 50 and older, need imaging
Major Category: Circulatory
-Vital Signs: Pulse rate, Blood Pressure. -Physical Exam: Palpate Pulses, Auscultate Heart, Auscultate Arteries
Major Category: Neurologic
Muscle Weakness or Spasm, Reflex Alterations, Sensory Loss, Pain which follows the distribution of: Nerve Root, Peripheral Nerve
Major Category: Iatrogenic
History of Presence of Iatrogen (caused by another physician)
Major Category: Psychogenic
Diagnosis of exclusion
Patients with possible trauma and/or fall…
Yield possibility of fracture
When you suspect fracture, what are the possible observations in the pt’s PE?
Unusual head carriage, careful palpation of cervical SP, percussion of SP of C2 &C7, severely restricted active ROM.
When you suspect fracture, what is a must do ?
X-ray of the pt’s complete cervical spine
When you suspect fracture, what should you avoid ?
Passive motion testing
When does percussive pain present?
Fracture, Tumor, Osteomyelitis, Infectious Discitis, Facet Joint Synovitis
What are some red flags in a pt with facet dislocation?
Violent rotational injury, Can occur with sudden voluntary head turning, Patient may hear a “Click” as the facets lock, Pain is present at the site of injury
What are some physical findings in a pt’s with facet dislocation?
Abnormal head carriage-torticollis, Palpate Articular pillars for facet dislocation, Neurologic Exam, X-ray Confirmatory
Unilateral facet joint dislocation causes…
No neurologic compromise
Bilateral facet joint dislocation causes…
Compression of Spinal Cord
What symptoms will a pt with a herniated cervical disc present?
Neck pain which radiates into the shoulder, arm, forearm, wrist or hand
Describe the history of a pt with a herniated cervical disc due to trauma?
Presence of Pain which radiates into a dermatomal distribution. Numbness or Paresthesias in a Dermatomal Distribution
Describe the PE of a pt with a herniated cervical disc due to trauma?
Observe – May be abnormal head carriage and Loss or reversal of Cervical Lordosis. Palpate – Tenderness and muscle spasm at the level of the herniated disc
Describe the PE of a pt with a herniated cervical disc due to trauma? #2
Active ROM restricted in Flexion, may be restricted in other directions as well. Valsalva Test reproduces radicular pain.
Describe the PE of a pt with a herniated cervical disc due to trauma? #3
Flexion/Compression Test reproduces pain in nerve root distribution. Lhermitte Sign may be present
Valsalva Test
Reproduces the symptoms of any space occupying lesion within the spinal canal
Cervical Compression Test
Exert a downward (vertically) force in pt’s head. (perform only if valsalva is negative)
Distraction Test
With one hand in the pt’s occiputand the other under the pt’s chin, exert an upward force.
Lhermitte Sign
Electrical Shock Paresthesia down back, arms, legs with flexion of the neck. Occurs with any cause of spinal cord compression and with many causes of spinal cord inflammation
What other tests do you perform in a pt with a herniated cervical disc?
Sensory test for touch and pain. Muscle strength testingWa
Muscle strength testing for Herniated disc includes which muscles and vertebrae?
C5 – Deltoid C5 – Serratus Anterior C5/C6 – Biceps C6 – Wrist Extensors
Muscle strength testing for Herniated disc includes which muscles and vertebrae? #2
C7 – Triceps C7 – Wrist Flexors C7 – Finger Extensors C8 – Finger Flexors T1 - Interossei
Which reflexes are tested during the PE of a pt with herniated cervical disc?
C5 – Biceps Reflex C6 – Brachioradialis C7 – Triceps Reflex
If a pt with a herniated disc has a nerve root compression, what symptoms will he/she present?
Sensory Loss Muscle Weakness Reflex Loss
Spinal cord compression in a pt with herniated disc will cause…
Sensory Deficits, Muscle Spasticity, Hyperreflexia, Clonus, Abnormal Reflexes: Hoffman & Babinski
Describe the hoffman test
Squeeze the tip of pt’s middle finger
What would imaging show in a pt with a herniated disc?
straightening or reversal of cervical lordosis. MRI confirms neurologic findings
What are some findings seen during a PE of a pt with cervical s&s?
Flattening of Cervical Lordosis. Abnormal Head Carriage – Torticollis. Normal neurologic exam.
What muscles (or structures) may get tender and spastic in pts’ with cervical s&s?
SCM, scalene, paravertebral, superior trapezius border, levator scapula scapular attachment, nuchal ligament.
SCM tearing and hematoma formation may be caused by…
Hyperextension injury of neck (classic injury of whiplash)
When were head restraints first implemented in cars?
Late 1960s
What are some findings seen during a PE of a pt with cervical s&s? #2
Restricted and/or Asymmetric Active ROM, Neurologic Examination will be normal, Distraction Test may be painful
Distraction test in a pt with cervical s&s will cause…
Dolor
X ray of a pt with cervical s&s will show…
absence of fracture, loss of normal cervical lordotic curve
Which muscles are responsible for cervical s&s?
Scalenes Paravertebral
What can cause Torticollis?
Strain Sternocleidomastoid Muscle
Strain Scalene Musculature
Muscular Ischemia
Facet Dislocation with Overriding (C2 to C7)
C1-C2 Dislocation
Congenital Torticollis
The condition has been present since birth
How would you asses a newborn for congenital torticollis?
By testing cervical range of motion in sidebending and rotation
Normal – 30 degrees sidebending, 90 degrees rotation
What percentage of healthy new borns have Torticollis?
16%
What are the risk factors for Congenital torticollis?
Mother feeling the fetus “stuck” in one position for six weeks or more.
Presence of other Birth Trauma
–Cephalohematoma
–Clavicular Fracture
–Brachial Plexus Injury
Prolonged Second Stage of Labor
List the congenital etiologies of Torticollis
Klippel-Feil Syndrome
Basilar Impression
Atlanto-occipital Fusion
Pterygium Colli (web neck)
Odontoid Abnormalities
Klippel-Feil Syndrome
Cervical Spine congenital anomaly consisting of multiple fused vertebrae, possibly Hemivertebrae and other anomalies
Hypoplastic dens may be present in
Achondroplastic Dwarfism
Down Syndrome
Patients with Klippel-Feil Syndrome will present with…
Localized neck pain.
Significantly reduced cervical range of motion.
Segmental motion testing demonstrates total motion loss, not just restriction
Inflammatory Etiologies of Torticollis
Lymphadenitis in the Neck-causes SCM spasm
Tuberculosis
(Vertebral Destruction,Muscle Spasm)
Typhoid
(Muscle Spasm)
Rheumatoid Arthritis
(Spontaneous Atlanto-axial rotatory subluxation)
How does Rheumatoid Arthritis causes Torticollis?
It erodes away the Transverse Odontoid Ligament with subluxation of the dens posteriorly into the spinal canal
If patient has evidence of RA elsewhere in the body…
Perform flexion/extension films of the odontoid before considering a manipulative approach
List the neurologic etiologies of torticollis
Ocular Dysfunction
Syringomyelia
Spinal Cord Tumor
Cerebellar Tumor
Bulbar Palsies
Spasmodic Torticollis
Facts about Syringomyelia
Central Cavitation of the Spinal Cord
M:F – 7:3
Symptoms appear during the 2nd & 3rd Decade of Life
Usually lower cervical to upper thoracic covering 6-7 spinal segments
What are some symptoms of Syringomyelia? #1
Restricted RROM
Awkwardness and Weakness of the Hands & Fingers.
Muscle Atrophy and Contracture, development of a “Claw Hand”
Radicular pain is unusual and if present mild
What are some symptoms of Syringomyelia? #2
Impaired pain and temperature sensation
Preservation of muscle sense and light touch
Vibration and Position sense are often defective
Hyperactive Deep Tendon Reflexes
Loss of Balance is a Possibility
Signs of Syringomyelia
Neck pain, kyphosis, scoliosis
Torticollis can also be seen in…
Acute Idiophatic Cervical Disc Calcification
Sandifer’s Syndrome (hiatus hernia, gastroesophageal reflux)
RED FLAGS for possible infection
Age Over 50 Years
Age Under 20 Years
Fever or Chills
Pain worse supine
Recent Urinary Tract Infection
IV Drug Abuse
Immune Suppression
What are some red flags you can find during a physical examination?
–Fever
–Spinous Process Percussive Pain
C2, C7 & T1 Only ones that can be percussed
What are some red flags you can find in labs?
–Elevated wbc count
–Elevated Erythrocyte Sedimentation Rate
What are some possible infections related to neck pain?
Sinusitis
Cervical Adenitis
Parotitis
Lyme Arthritis
Osteomyelitis
List the red flags for a possible tumor
–Age over 50 years
–Age under 20 years
–Unexplained Weight Loss
–Pain worse when Supine
–Severe Nocturnal Pain
Anyone with a history of cancer…
has METASTATIC CANCER until you can prove they don’t
List some tumors you can find in the neck
Parotid Tumor
Lymphoma
Lymphangioma
Neuroma
Meningioma
Metastatic Lung Cancer
When suspecting a circulatory disorder, what should be checked during the PE?
BP, Pulse Rate, Palpate Carotid Pulses(presence, character, thrill),
Auscultate: Heart (murmurs),
Carotid Arteries (bruits),
Vertebral Arteries – at mastoid processes (bruits), Ophthalmic Arteries – over the eyeballs (bruits)
Red flags for vertebrobasilar artery compromise
Have the sitting patient look up toward the ceiling then turn the head to right. Hold for three seconds, then return to neutral. Repeat for the Left Side
Observe for the development of nystagmus.
Is the DeKleyn test recommended when there is a suspicion of vertebrobasilar artery compromise?
NO
Suspect Cerebral Ischemia when…
Patient shows signs of anxiety or panic druing examination or treatment
What causes Wallenberg Syndrome?
vertebrobasilar thrombosis
Symptoms of Wallenberg Syndrome
–Homolateral facial pain
–Homolateral facial paresthesia
–Contralateral loss of sensation for pain and temperature on limbs & trunk
More symptoms of Wallenberg Syndrome
–Intense Vertigo with Vomiting
–Unilateral Paralysis of the Palate, Pharynx & Vocal Cords with “brassy” dysarthria
Dysphagia
Ataxia
Unilateral Horner Syndrome
Ischemia can be provoked by…
rotation of the neck combined with hyperextension
Are mechanical abnormalities typically insidious?
YES
What are some mechanical abnormalites?
Somatic Dysfunction
Kyphosis with Anterior Head Carriage
Scoliosis
Poor Posture
Poor Muscle Tone
Scapulo-Costal Syndrome
Hypermobility
What is important in a patient with somatic dysfunction before OMT?
Discover any contraindications
Somatic dysfunction acompanies and magnifies…
neck pain
What did a study say about OMT in patients with somatic dysfunction ?
Immediate pain relief was seen in both group- patients receiving OMT and patients on Ketorolac Tromethamine IM. However OMT patients showed greater decrease in pain. At 1 hr after treatment there was no significant difference in the 2 groups.
What is the characteristic posture of scapulo-costal syndrome?
Increased kyphosis with anterior head carriage is typically present in many patients with muscular neck, shoulder & upper back pain
Scapulo-Costal Syndrome
30% of all neck & shoulder complaints in midlife
Also called –
–Fatigue Postural Paradox Syndrome
–Levator Scapulae Syndrome
Where is the scapulo-costal syndrome pain localized?
In the superior medial corner of the scapula
Characterize Scapulo-costal syndrome
(AKA computer invoked myofascial shoulder pain)
Tenderness at the insertion of the levator scapulae muscle
Pain is exacerbated by elevation and adduction of the Humerus
Inflammation followed by fascial scarring in the scapulo-costal fascia will cause crepitance or gross crunching with scapular circumduction
What is the treatment for Scapulo-costal syndrome? #1
Correct Kyphosis
Correct Scoliosis
Correct Associated Cervical, Thoracic, Costal and Clavicular Somatic Dysfunctions
What is the treatment for Scapulo-costal syndrome? #2
Balance Shoulder muscle tension
Trigger Point Treatment
–Counterstrain
–Muscle Energy
–Deep Inhibitory Pressure
–Spray & Stretch
–Injection of Lidocaine/Corticosteroids
Describe Intern’s neck
Neck and Shoulder Pain
Caused by Excessive Pull on the Suspensory Muscles of the Shoulders
Etiology of Intern’s neck
Overloading the Pockets of the Great White Coat
Transfer Weight Off the Shoulders and onto the Pelvis Which is Better Designed to Handle the Load – Wear a carpenter’s Utility Belt
Some facts about hypermobility syndrome
Can occur in any joint including the spine
Can be localized due to ligamentous trauma, or local degenerative disc disease
Can be generalized due to genetic collagen defects resulting in laxity of ligaments
How to treat Localized Hypermobility syndrome #1
OMT:
–Treat Adjacent Spinal Regions That May be Restricted
–Correct, if possible, greater postural deformities
Exercise:
–Strengthen musculature that crosses the segment or joint
Postural Reeducation
How to treat Localized Hypermobility syndrome #2
Bracing
–No Bracing Without Exercise at Same Time
Prolotherapy
–Takes Two to Four Months to Work
Surgical Fusion
–Treatment of Last Resort – Patient Must Meet the Criteria for Surgical Level Instability
Ehlers-Danlos Syndrome
A group of inherited disorders that affect connective tissue due to defects in collagen production
There are Eleven Subtypes
What are other names for Ehlers-Danlos Syndrome type III?
Hypermobility type III
Benign hypermobility syndrome
Arthrochalasis multiplex congenita
Symptoms of Ehlers-Danlos Syndrome type III
loose unstable joints
chronic joint pain
Signs & symptoms of Ehlers-Danlos Syndrome classical type (I &II)
Highly Elastic, Velvety Skin
Fragile Skin that Bruises and Tears Easily
Slow and Poor Wound Healing Leading to Scarring
Non-cancerous fibrous growths on pressure areas such as elbows and knees
Fatty Growths on Shins & Forearms
Loose Joints, Prone to Dislocation, Delayed Development of Large-Motor Skills
Signs & symptoms of Ehlers-Danlos Syndrome vascular type (IV)
Fragile Blood Vessels and Organs that are Prone to Rupture
Thin, Fragile Skin that Bruises Easily
Veins Visible Beneath the Skin
Distinctive Facial Features Including Protruding Eyes, Thin Nose & Lips, Sunken Cheeks and Small Chin
Loose Joints Usually Limited to Fingers & Toes
Signs & symptoms of Ehlers-Danlos Syndrome kyphoscoliosis (VI)
–Progressive Scoliosis
–Fragile Eyes That are Easily Damaged
–Severe, Progressive Muscle Weakness
Signs & symptoms of Ehlers-Danlos Syndrome arthrochalasia (VII A & B)
–Very loose joints and dislocations, involving hips, which may delay development of large motor skills
–Stretchy Skin that’s Prone to Bruising
–Early Onset Arthritis
–Increased Risk of Osteoporosis
Signs & symptoms of Ehlers-Danlos Syndrome dermatosparaxis (VII C)
–Extremely Fragile and Sagging Skin
–Loose Joints, may see Large Motor Delay
List the incidences of Ehlers-Danlos Syndrome subtypes
Type III: 1 in 10-15,000
Typer I & II: 1 in 20-40,000
Type IV: 1 in 100-200,000
Type VI: 60 cases ever reported
Type VII A & B: 30 cases ever reported
Typer VII C: 10 cases ever reported
Ehlers-Danlos Syndrome diagnosis
Genetic test, skin biopsy, cardiac ultrasound
Ehlers-Danlos Syndrome complications
Prominent Scarring
–Difficulty with Surgical Wounds Healing
–Chronic Joint Pain
–Early Onset Arthritis
–Premature Aging with Sun Exposure
Ehlers-Danlos Syndrome more complications
–Rupture of Major Blood Vessels, Intestines, Uterus.
–Eye Problems
–Osteoporosis
–Premature Delivery of Fetus
–Premature Rupture of Fetal Membranes
Ehlers-Danlos Syndrome self care
–Avoid Injury
–Use Protective Gear
–Reduce Clutter
–Use Assistive Devices
–Wear Sunscreen
Ehlers-Danlos Syndrome treatment
–OMT: Same as for benign hypermobility
–Stabilization Exercises
–Vitamin C (May help)
List the possible temporomandibular joint dysfunction
Joint Disease
Dental Malocclusion
Dysfunction of Muscles of Mastication
Head Carriage
Cranial Somatic Dysfunction
Psychological Issues
History of Degenerative diseases
Insidious onset, age over 50 years
**requires imaging
List the possible degenerative diseases
Cervical Spondylosis
Diffuse Idiopathic Skeletal Hyperostosis
Osteoarthritis – Shoulder
Osteoarthritis - TMJ
What is common in patients with cervical disc disease (cervical spondylosis)?
Headache
For cervical spondylosis headache, what is the right way to declare the etiology?
Declare etiology of headache based on x-ray AND physical findings
What is DISH?
Diffuse Idiopathic Skeletal Hyperostosis
Facts about DISH #1
In the cervical spine it can result in Ossification of the Posterior Longitudinal Ligament
More common in persons of Japanese descent
Facts about DISH #2
Symptoms range from asymptomatic –to–
quadriplegia from minor injury
Long Track Symptoms & Signs usually develop gradually over a period of years
DISH exhibits…
Candle wax osteophytes
DISH is related to what other disease?
Diabetes Mellitus Type II
pts need to have fasting blood sugar tested
Thoracic Outlet Syndrome
Insidious onset, it may also follow trauma
Syndromes caused by Thoracic Outlet Syndrome
Anterior Scalene Syndrome
Costo-clavicular Syndrome
Pectoralis Minor Syndrome
Somatic Dysfunction
–Cervical
–1st & 2nd Rib
–Clavicle
Exposure to the toxin may be:
Vocational
Avocational
Incidental
Etiologies of metabolic disorders
Nutritional
–Ingestion
–Digestion
–Excretion
Endocrine
What laboratory screening test should be perform in pts with toxic and metabolic disorders?
–CBC
–Urinalysis
–Blood Chemistries: Glucose, BUN, Creatinine, Electrolytes, Calcium, Protein, Albumin, Globulin, Bilirubin, Alkaline Phosphatase, AST, ALT, TSH, T3/T4
What are some metabolic disorders?
Hyperthyroidism
Hypothyroidism
Hypokalemia
Hypomagnesemia
Hyperthyroidism
Muscle Weakness & Atrophy
Hypothyroidism
Brisk reflex contraction with slow relaxation
Hypokalemia
Muscle Weakness, Cramping, Fasciculations
Hypomagnesemia
Weakness, Tetany, Carpopedal Spasm, Positive Chvostek Sign
Chvostek Sign
Facial muscles involuntarily contract when the facial nerve is percussed
Failed Sugeries
Cervical Spine
Dental
Ophthalmologic
Otolaryngologic
Referred pain FROM Head & Neck
Breast Pain
–C5/C6 nerve root {myotomal pain}
Precordial Pain
–C5/C6 nerve root {myotomal pain}
Facial Pain (Trigeminal Neuralgia)
Referred pain TO Neck & Head
Cardiac Pain
Complex Regional Pain Syndrome
(Reflex Sympathetic Dystrophy Syndrome)
(Barre’-Leiou Syndrome)
Dental Pain
Myofascial Trigger Points
Occipital Neuralgia
Ocular Pain
