Neck pain Flashcards
common patient presentations
acute injury and/or arm pain
acute, pseudo-torticollis
postural pain or stiffness due to poor ergonomics
decreased ROM associated with stiffness or pain
headaches
C2-3 problems normally refer to?
the head
C3-4 problems normally refer to?
lateral neck from head to base
C4-5 problems normally refer to?
whole side of neck from head to base and into shoulder
C5-6 problems usually refer to?
lower lateral neck and into shoulder
C6-7 problems usually refer to?
shoulder to upper mid back
neck pain and arm pain is most likely from?
a facet joint
does neck pain and arm pain have neurological deficits?
no, even though there might be complaints of numbness or tingling
what red flags should you look out for?
trauma history of cancer corticosteroid use history of infection head trauma with loss of consciousness nuchal rigidity bladder dysfunction associated with onset of neck pain associated dysphagia associated CN or CNS signs/symptoms onset of new headache pre-existing conditions
what other things should you look for in the history?
nuchal rigidity/ positive brudzinski’s or kernig
suspected fracture, dislocation, infection, cancer
perform examinations
what tests should you do if there is only neck pain
inspection observation of patient's movements static palpation motion palpation P and AROM functional assessment and orthopedic screening
what tests should you do if there is neck and arm pain?
orthopedic/neurological exam, compressive and neural stretch testing, nerve stretch maneuvers, DTR testing, sensory examination and myotome testing
when should you xray someone with neck pain?
if you suspect fracture, dislocation, infection or cancer
or if they have radicular findings
when should you perform MRI for neck pain?
ddx of radicular or myelopathy cases to further evaluate stenosis, tumor, herniated disc or multiple sclerosis
when should electrodiagnostic studies be done?
when radicular complaints remain unclear
pain that radiates into the arm indicates?
disc lesion, nerve root entrapment, referred pain, myelopathy, brachial plexus involvement
isolated weakness or numbness suggests?
nerve root involvement
numbness and tingling in a diffuse or ill-defined pattern suggest?
referred pain from facet or trigger points
what is a red flag for infeciton, tumor or vascular etiologies?
neck pain with a “new” headache or the worst headache they have ever experienced
lateral flexion neck injuries
compression injury on side of movement and stretching injury on the opposite side
forced flexion neck injuries
compression fracture, myelopathy from stenotic canal considered with arm and leg complaints
what is the primary intention of orthopedic testing?
to compress or stretch pain producing structures such as facets and NRs
standard orthopedic tests
various forms of cervical compression cervical distraction shoulder depression brachial plexus stretch testing soto hall lhermitte's
cervical compression test
local pain on extension and/or rotation indcates facet involvement, while radiating pain down the arm indcates nerve root involvement
cervical distraction test
an attempt to reduce local or radiating complaints if painful, muscle splinting is suggested
lhermitte’s
passive flexion of neck that causes electric shock sensations, seen with MS or cervical myelopathy
upper limb tension test
also known as brachail plexus test
good screening test to rule out cervical radiculopathy
pain on contralateral cervical side bending
decrease in symptoms with ipsilateral dise bending
what is the classic presentation of cervical radiculopathy
patient comlains of neck and arm pain
onset follows a neck injury, may be insidious
what is often the history of cervical radiculopathy
multiple bouts of neck pain following minor injuries
patient also complains of weakness in the hand
bakody’s sign
some cervical radiculopathy patients have a positive bakody’s signs
describe tests for cervical radiculopathy
AROM and PROM painful restriction C compression may reproduce pain cervical distraction may relieve arm pain bakody's may be positive decreased DTR weakess in related myotome sensory abnormality
C5
motor supply to deltoid (shoulder abduction) and biceps (elbow flexion/supination) biceps relfex, sensory to outer shoulder (axillary N)
C6
motor supply to biceps and wrist extension
brachioradialis reflex
sensory to outer forearm
C7
motor supply to triceps (elbow extension), finger extensors and wrist flexors
triceps reflex
sensory to middle finger
C8
motor supply to finger flexors
no reflex
sensory to little and ring fingers
T1
motor supplied to the interosseous muscles of hand (abducion of fingers) no reflex and sensory to medial arm
midline C spine disc herniations create
myelopathies
lateral disc herniations in C spine do what?
compress NR below
midline disc herniation in L spine does what?
compress NR below
foraminal disc herniation in the L spine does what?
involves the NR at the same level
disc herniationin C spine?
affects NR below
hypertrophy of uncinate will affect?
NR at same level
disc herniation at C7/T1 will affect
C8 NR
hypertrophy changes of T1 vertebral body will affect
C8 NR
patient presentation wilth myelopathy can differ based on what?
type and degree of compression
what are the classic patient symptoms of myelopathy?
bilateral symptoms of clumsiness of hands, difficulty walking, possible urinary dysfunction, possible shooting pains into arms
what are some causes of spinal cord compression?
tumor
herniated disc
spondylolytic sources
direct pressure on posterior columns causes disturbances in?
vibration perception
proprioception
what tests may be positive with myelopathies?
pathological reflex
decrease strength, proprioception, vibration
Lhermitte’s
what measurement indicates concern for spinal stenosis? indicates stenosis?
<13mm
<11mm
cervical spondylolotic myelopathy
severe canal stenosis, significant cord compressions with changes of myelomalacia
symptoms of TOS
diffuse arm symptoms, including numbness and tingling
they often describe a path down the inside of the arm to the 4th and 5th digits with overhead activity
what can be compressed in TOS?
brachial plexus
subclavian/axillary arteries
what are some reasons for TOS?
elongated C7 TVP cervical rib scalene muscles costoclavicular area subcoracoid area pec minor
how is grip strength and reflexes for TOS?
grip strength reduced
relfexes normal
what test is positve if the TOS is because of the scalene muscles?
adson’s, halstead’s
what test if positive if the TOS is because of pec minor?
wright’s
what functional test is positive for TOS?
Roo’s
symptoms patient might copmlain of with a facet problem
traumatic ir insidious onset of neck and arm pain that doesn’t folow a specific dermatome
what is the most common location for facet symptoms?
down outer arm to hand (C5-7 facet joints)
how can you tell the difference between referred pain and facet pain?
referred pain rarely goes to the hand
how is pain reporduced in facet syndrome?
cervical compression with neck in extension and rotated to involved side
what may be warranted with facet syndrome?
xrays
how will you know if a baby has congenital torticollis?
there will be fixed asymmetry of the head seen within hours or sometimes weeks of the delivery
what will an adult with congenital torticollis experience?
painful muscle spasms of SCM, causing the head to be held in rotation and sometimes slight flexion
pseudo-torticollis
inability to move head in any direction without pain with head held in neutral position
what is a cerviacl sprain/strain?
overstretch or over contraction with possible radiation
cervical sprain/strain valsalva's ROM orthopedics neurological AROM PROM
valsalva’s: no radiation
ROM: contraction of muscle orstretch of muscle or joint
orthopedics: none
neurological: none
AROM: pain that contracts involved muscles
PROM: pain that contracts involved muscle or ligament
what is helpful as a treatment for cervical sprain/strain?
if significant trauma: radiographs myofascial therapy limit orthotic support ergonomic advice preventative exercises and stretches
if the cervical sprain/strain is unstabile, what do you need to do?
orthopedic consult
