Neck Flashcards
What are the 7 serious conditions that can present with neck pain?
CAD Stroke / haemorrhage Myocardial ischaemia Meningitis Osteomyelitis Bone tumour Vertebral fracture
What are the 4 types of vertebral fracture that can occur in the cervical spine?
Avulsion
Jefferson (C1)
Odontoid (C2)
Pars
What are the red flags in a neck pain presentation that can indicate CAD?
- Acute onset unilateral neck pain with unilateral HA
- dizziness
- asymmetrical CN
- Horners
- tinnitus
- vision / speech change
- decreased co-ordination
What are the red flags in a neck pain presentation that can indicate a tumour?
- over 50
- history of malignancy
- unexplained weight loss
- failure to improve
- dysphagia
- headache
- vomiting
What are the red flags in a neck pain presentation that can indicate a fracture?
- traumatic onset (including minor trauma if over 50, osteoperosis or corticosteroid use)
- long term corticosteroids
Other signs:
- bone pain
- pain at night and rest
- may have: altered consciousness, double vision, dysphagia, radiculopathy or deficits in Cx and UL
- may have SSX of cervical instability in the case of an odontoid fracture (nystagmus, lip paraesthesia, overt loss of balance with head movements)
What are the signs that a neck pain presentation is caused by myocardial ischaemia?
- chest pain
- pain may radiate to shoulder and arm (left more than right), jaw and interscap region
- pallor
- sweating
- dyspnoea / SOB
- tachycardia / palpitations
- severe fatigue
- SSX aggravated by exercise and stress
Describe the presentation of meningitis
- severe throbbing HA and severe neck pain
- nuchal rigidity
- pain worsened by neck flexion
- fever
Potential signs:
- rash
- joint pain
- fatigue / malaise
- nausea / anorexia / vomiting
What are 4 neurological causes of neck pain to consider?
Thoracic outlet syndrome
Radiculopathy
Myelopathy
Burners / stingers
What are 6 musculoskeletal / discogenic causes of neck pain to consider?
Facet sprain Muscle strain Acute torticollis Whiplash Cervical spondylosis Annular fissure (disc) Disc herniation
What are 5 rheumatological causes of neck pain to consider?
Rheumatoid arthritis Ankylosing spondylitis Fibromyalgia Paget's disease Polymyalgia rheumatica
What are some common PROMs to use in neck pain presentations?
NDI (Neck Disability Index)
NPAD (Neck Pain and Disability Scale)
Describe the condition of a cervical facet sprain
(Very common)
Pain:
- unilateral dull / aching constant pain, sharp w/ agg movement
- may have radicular pain
- may radiate to head, face ear (upper Cx) or shoulder, suprascap (lower Cx)
Pattern:
- agg. by movement, particularly extension, ipsilateral sidebending, and rotation
- agg. by prolonged sitting or overuse
Mechanism:
- postural strain
- overuse
- Cx degeneration
- minor or major trauma
Findings:
- decreased Cx ROM
- increased Cx tenderness and hypertonicity
- point tenderness over facet
Healing timeframes:
- pain free 2-3/52
- complete healing: 4-6/52
Describe the condition of acute torticollis
- acute onset severe tightness and spasm of unilateral Cx mm
Mechanism:
- mild trauma (ie: poor sleep posture, unaccustomed activity)
- underlying facet or disc pathology
- medication / substance
Advice:
- self-limiting (focus on patient reassurance) within 2-7/7
Describe the 5 types of disc pathology
Annular fissure:
- tearing of annulus fibrosis (only outer third of fibres are nociceptive)
Protrusion:
- annulus intact but nucleus protrudes into disc
Prolapse:
- annulus intact but nucleus forced into outer layer of annular
Extrusion:
- small annular breach, fluid moves into epidural space
Sequestration:
- annular breached, nucleus fragments detach
What is the typical mechanism, typical findings and healing timeframes for discogenic pathologies in the neck?
Mechanism:
- can be acute or insidious
- typical mechanism of injury: flexion with rotation
Findings:
- pain is variable: can be centralized, unilateral or asymptomatic
- pain typically dull with sharp aggravations
- may cause radicular pain in in affected dermatome
- pain aggravated by Cx flexion
- may have unilateral UL neuro findings if spinal nerve affected (bilateral neuro findings indicate myelopathy and requires emergency referral)
Healing timeframes:
- annular fissure: usually self-limiting
- disc herniation: resolution within 3-6/12
- radiculopathy: SSX reduction within 1-2/52; resolution within 3-6/12
What are the normal healing timeframes for a muscular strain?
Grade 1: 2-3/52
Grade 2: 2-3/12
Grade 3: surgical repair
Describe the presentation and treatment of whiplash
Mechanism:
- traumatic onset involving rapid acceleration / decceleration (MVA, diving injury, contact sports, collision) causing rapid hyperextension - hyperflexion - hyperextension of neck
Presentation:
- neck pain, may radiate to shoulders, subocc and intercap region
- decreased Cx ROM
- Cx hypertonicity
- protective spasm of deep neck flexors
Associated disorders:
- can cause multiple other pathologies including facet sprain, disc injury, muscular injury, myelopathy, radiculopathy
- highly co-morbid with depression, anxiety, PTSD, mood disturbance
Management:
- must be referred to a medical professional for screening and management
- use psychosocial screening tools
- follow whiplash guidelines
Describe the presentation, findings and treatment for thoracic outlet syndrome (neurological)
Presentation:
- unilateral neck pain, maybe radiating into GH & UL
- pain is radicular / aching in quality and can be intermittent or constant
Agg by:
- UL movement, esp. OH
- sleeping on arm
UL Neuro:
- paraesthesia
- decreased grip strength, early fatigability
- decreased co-ordination and propioception
- diminished reflexes
(sensory SSX precede motor SSX)
Clinical:
- positive Roos Stress test, Wright’s test, Eden’s test, ULNTs, Tinel’s (brachial plexus)
Treatment:
- address cause of restriction (at the scalene triangle, costoclavicular space and/or underneath pec minor)
- ULNT glides / flosses
- complete resolution typically possible
Describe the presentation, findings and treatment of thoracic outlet syndrome (vascular)
Pain:
- unilateral neck, may radiate to GH and UL
- pain can be intermittent or constant
Pattern:
- UL becomes painful, swollen and blue with strenuous or prolonged activity
- sense of heaviness / fatigue in arm esp. with mvmt or elevation
Agg by:
- UL movement, esp OH
- sleeping on arm
Other SSX:
- pallor / cyanosis
- coldness in UL
- mm atrophy / weakness / cramping
- ischaemic pain and exertional fatigue
- UL oedema (non-pitting)
Findings:
- asymmetrical decreased radial HR
- asymmetrical brachial BP
- asymmetrical decreased capillary return
- asymmetrical distal coldness
- positive Allens and Adson’s test
Emergency referral
Which tests should be performed if vascular thoracic outlet syndrome is suspected?
Peripheral CVD:
- look for asymmetrical radial HR, asymmetrical BP, asymmetrical diminished capillary return, asymmetrical positive Allen’s test, asymmetrical distal coldness
Adson’s test
- decrease or disappearance of radial pulse indicates vascular TOS
Emergency referral if vascular TOS suspected
What is the most sensitive clinical test to perform for neurological thoracic outlet syndrome?
Roos / EAST test (chicken dance)
Describe the condition of cervical radiculopathy including presentation, pathology, findings and prognosis
Presentation:
- typically unilateral radicular pain in Cx and affected dermatome
- pain agg. by Cx extension and flexion, and ipsilateral rotation
Pathology:
- compression or irritation of the Cx spinal nerve
- common causes: disc herniation, disc pathology causing local inflammation, Cx stenosis / osteophytic growth, local or referred inflammation of the nerve root
Findings:
- sensory changes in a dermatomal pattern
- motor changes (weakness) in a myotomal pattern)
- diminished reflexes
Ortho tests:
- positive Spurlings, distraction and maybe ULNT tests
Prognosis:
- SSX reduction 4-6/12
- recovery 1-3 yrs in most cases
- if underlying factors cannot be resolved, may need management rather than full recovery
Describe the condition of burners / stingers including presentation, mechanism, grades of nerve injury, and prognosis
Pain:
- unilateral radicular (burning / shocking)
- supraclavicular, maybe radiation to UL
Other:
- UL paraesthesia, numbness and weakness
Mechanism:
- traumatic injury to upper trunk of brachial plexus or C5-6 spinal nerve roots
- can be caused by traction or compression
Nerve injuries:
- Grade 1 (neurapraxia): demyelination (3/52 healing)
- Grade 2 (axonotmesis): axonal damage and Wallerian degeneration (slow regeneration 1mm / day)
- Grade 3 (neurotmesis) - rare, completely severed nerve, requires intervention and typically not able to achieve full recovery
Describe the condition of cervical myelopathy including presentation, mechanism and pathology, findings and prognosis
Pain:
- insidious onset bilateral Cx pain, maybe occipital headache, LBP and leg pain
UL and LL Neuro findings:
- hyperreflexia
- clonus with reflexes
- Babinsi sign
- spasticity LL
- decreased pain sensation
- paraesthesia
- decreased motor strength, co-ordination and propioception
- gait change, clumsiness
Mechanism and Pathology:
- compression of spinal cord in Cx vertebral canal
- can cbe secondary to Cx spondylosis / osteophytic growth, disc herniation, traumatic injury, space occupying lesion
- affects both ascending and descending pathways, and innervation of both upper and lower limbs
Prognosis:
- emergency referral
- complete resolution usually not achievable (often degenerative and progressive)
What findings can differentiate a radiculopathy from a myelopathy in the cervical spine?
Myelopathy: affects upper and lower limbs; radiculopathy: affects upper limb only
Signs present in myelopathy and not radiculopathy:
gait change / ataxia, hyper-reflexia, clonus with reflex, spasticity LL
What is the difference between stenosis, spondylosis, spondylolysis, and spondylolisthesis?
Stenosis: narrowing of Cx spinal canal
Spondylosis: OA of Cx vertebrae / discs
Spondylolysis: Pars fracture
Spondylolisthesis: anterior displacement of vertebrae (often secondary to a pars fracture)
What part of the vertebrae is injured in a pars fracture?
The pars interarticularis (between the superior and inferior articular facet)
Describe the pathology of cervical spondylosis
- also referred to as OA or DJD of the cervical spine
- progressive degeneration of cervical joints (DJD) and/or discs (DDD)
- discs dehydrate and shrink over time, and/or cartilage in facet joints deteriorates
- causes compression of vertebral column and intravertebral foramen
- bony osteophytes may develop to ‘hold’ vertebral space open
Describe the typical presentation and findings with cervical spondylosis
Presentation:
- variable: can have mild - severe pain, or can be asymptomatic
- usually insidious onset
- if pain: agg. by Cx movements (esp. flexion and extension)
Potential findings (not always present):
- diminished UL reflexes, motor strength, sensation
- radiculopathy
Potential SSX (not always present)
- cervicogenic headache
- Cx radiculopathy
- Cx myelopathy
Cx findings:
- decreased Cx ROM
- increased Cx hypertonicity
What are the typical mechanisms for developing spondylolisthesis?
- hyperextension overuse (gymnastics, yoga, diving)
- underlying pars fracture (spondylolysis)
- underlying degeneration (spondylosis)
Describe the condition of rheumatoid arthritis, including pathology, presentation, and management
Pathology:
- chronic inflammatory autoimmune condition
- causes deterioration of synovial joint membrane, tendons and ligaments
- can cause joints to lose alignment and integrity
- can cause myelopathy / radiculopathy / spondylolisthesis
Presentation:
- variable neck pain (mild to severe)
- may have radicular pain, cervicogenic headache, and/or UL paraesthesia
- SSX usually worse in the am and after inactivity, and improves with movement
Treatment:
- no cure
- typically progressive in periods of flares and remission
- medical referral for management
