E4: Differential Diagnosis of Neck Pain Flashcards
What are some congenital etiologies of torticollis?
Trauma at birth Klippel-Feil syndrome Basilar impression Atlanto-occipital fusion Pterygium colli (web neck) Odontoid abnormalities
What is Klippel Feil syndrome?
Cervical spine anomaly consisting of multiple fused vertebrae, possible hemivertebrae or other anomalies
On physical exam, what signals Klippel Feil syndrome?
Segmental motion testing demonstrates total motion loss, not just restriction.
What are some inflammatory etiologies of torticollis?
Lymphadenitis in the neck
Tuberculosis
Typhoid
Rheumatoid arthritis *most common - causes spontaneous Atlanto-axial rotatory subluxation
How does rheumatoid arthritis induce torticollis?
It erodes away the transverse odontoid ligament with subluxation of the dens posteriorly into the spinal canal
If a patient presents with neck pain and has RA elsewhere in the body, what should be done before taking a manipulative approach?
Perform flexion/extension films of the odontoid
What are some neurologic etiologies of torticollis?
Ocular dysfunction Syringomyelia Spinal cord tumor Cerebellar tumor Bulbar palsies Spasmodic torticollis
What is syringomyelia?
Central cavitation (dilation) of the spinal cord
When do symptoms of syringomyelia typically appear?
Second/third decade of life
Which demographic is more affected by syringomyelia?
Men
M:F - 7:3
What is the calling card of syringomyelia?
Awkwardness/weakness in the extremities
“Claw hand”
Radicular pain is UNUSUAL
What are the red flags for possible infection with neck pain?
Age: >50 years or <20 years Fever or chills Pain worse supine Recent UTI IV drug abuse Immune suppression
What are common infectious causes of neck pain?
Sinusitis Cervical adenitis Parotitis Lyme arthritis Osteomyelitis
What are the red flags for possible tumor with neck pain?
Age: >50 years or under <20 years
Unexplained weight loss
Pain worse when supine
Severe nocturnal pain
**NO fever
What Beighton score do most people with Ehlers-Danlos have?
7
What is the most common sub-type of Ehlers Danlos?
Type III - Hypermobility Type
1 in 10-15,000 people
What are hypermobile Ehlers Danlos patients prone to?
Chronic joint pain
What is Classical Type Ehlers Danlos and what are the symptoms?
Types I and 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
What is a major implication of Type IV Ehlers Danlos?
Type IV = Vascular Type
Fragile blood vessels and organs are prone to rupture
Percussive pain is present with which conditions?
Fracture Tumor Osteomyelitis Infectious discitis Facet joint synovitis
Neck pain that radiates into shoulder, arm, forearm, wrist, or hand indicates which condition?
Herniated cervical disc
This technique will make the symptoms of any space-occupying lesion in the spinal canal worse.
Valsalva maneuver
What aspects of patient’s history would indicate herniated cervical disc?
Pain that radiates into a dermatomal distribution
Numbness/paresthesias in a dermatomal distribution
PE findings that indicate herniated cervical disc
Abnormal head carriage
Loss or reversal of cervical lordosis
What is Lhermitte sign?
Electrical shock paresthesia down back, arms, or legs with flexion of the neck
When does Lhermitte sign occur?
With any cause of spinal cord compression
Occurs with many causes of spinal cord inflammation
Nerve root compression results in reflex _____. Spinal cord compression results in reflex _____.
Loss
Abnormality
Hoffman test
Support the middle finger and then flick it
Positive sign: thumb and pointer finger move
Hypoplastic dens may be present in which demographic?
Dwarfism
Down Syndrome
Syringomyelia patients typically do not have _____.
Pain
If patient has rheumatoid arthritis elsewhere in the body, what should you do before a manipulative approach?
Perform extension/flexion films of the odontoid to determine stability
Which mechanical abnormality is most common in people over 50?
Kyphosis with anterior head carriage
Where is point tenderness for Scapulo-Costal syndrome?
Insertion of the levator scapulae muscle
What movement exacerbates Scapulo-Costal syndrome?
Elevation and adduction of the humerus
Using a brace for localized hypermobility treatment also requires the patient to do what?
Exercise. Lack of exercise will make them more unstable.
Possible treatment for localized hypermobility
OMT Exercise Bracing Prolotherapy Surgical fusion
Complications of Ehlers-Danlos
Prominent scarring Difficulty with surgical wounds healing Chronic joint pain Rupture....of everything Premature aging with sun exposure Early onset arthritis
Ehlers-Danlos treatment
OMT (same as for benign hypermobility)
Stabilization exercises
Vitamin C
What is Chvostek sign?
Facial muscles involuntarily contract when the facial nerve is percussed.
Sign of hypocalcemia.
Most common failed surgeries that cause neck pain
Cervical spine
Dental
Ophthalmologic
Otolarynologic
Pain referred FROM the head and neck
Breast pain (C5/C6 nerve root) Precordial pain (C5/C6 nerve root) --> pain in front of the heart Facial pain (trigeminal neuralgia)
Conditions that refer pain TO the head and neck
Cardiac pain Complex regional pain syndrome (Reflex Sympathetic Dystrophy Syndrome) (Barre-Leiou syndrome) Dental pain Myofascial trigger points Occipital neuralgia Ocular pain
