Neck pain & stiffness Flashcards
Probability diagnosis
Vertebral dysfunction (non-specific)
Traumatic ‘strain’ or ‘sprain’
Cervical spondylosis
Serious disorders not to be missed
Vascular
- angina
- subarachnoid haemorrhage
- arterial dissection
Severe infections
- osteomyelitis
- meningitis
- atypical infection, e.g. tetanus, leptospirosis
Neoplasia
- metastases
- primary tumour
- Pancoast tumour
Vertebral fractures or dislocation
Pitfalls (often missed)
- Disc prolapse
- Myelopathy
- Cervical lymphadenitis
- Fibromyalgia syndrome
- Outlet compression syndrome (e.g. cervical rib)
- Polymyalgia rheumatica
- Ankylosing spondylitis
- Rheumatoid arthritis
- Oesophageal foreign bodies and tumours
- Paget disease
- Herpes zoster
- Referred shoulder pain
Masquerades checklist
Depression
Thyroid disorder (thyroiditis)
Spinal dysfunction
Is the patient trying to tell me something?
Highly probable. Stress and adverse occupational factors relevant.
Key history
General pain analysis, especially the nature of onset, its site and radiation, and associated features.
Midline pain, e.g. spinal infection.
Night pain may suggest more sinister pathology.
Functional impairment
- Activities associated with pain
- Current limitations compared to usual activities of daily living
- Activities required at work (prompt return to work improves outcomes) and options for light duties
Check for presence of radicular pain in arm and paraesthesia or numbness, and for weakness in the arm.
If traumatic injury, consider mechanism, e.g. high speed
Co-morbidities, e.g. osteoporosis, rheumatoid arthritis, ankylosing disorder, corticosteroid use
Occupational history
Past history of neck pain and trauma.
Key examination
- Look, feel, move, measure, test function. 3 objectives of the examination:
- Check for mid‑spine tenderness, reproduce the pt’s symptoms.
- Do not assess ROM if midline tenderness or neurological symptoms/signs.
- Perform a neurological examination if radicular pain, weakness or paraesthesia is present in the arm
- identify the level of the lesion or lesions:
- Assess motor levels for weakness
- sensation with light touch and pin prick.
- biceps (C5/C6), brachioradialis (C6), and triceps (C7) reflexes.
- determine the cause (if possible)
- General examination
- Take temperature and pulse.
- Look for weight loss.
- Auscultate carotid arteries if anterior neck pain.
- Check range of motion in shoulders – rotator cuff pain can mimic spinal neck and radicular pain.
- If radiculopathy, differentiate from cubital or median nerve compression.
- If there is any suspicion of myelopathy (spinal cord compression), assess upper and lower limb, urinary & bowel function and assess gait.
Key investigations
Avoid investigations for low-risk patients with cervical pain.
If any red flags, or inflammatory arthritis is suspected:
- FBC, ESR/ CRP, ALP, Ca, Ph, RA factors
Imaging should be selected conservatively
Plain X-ray is not indicated in the absence of red flags and major trauma.
Consider X-ray spine if:
- low risk injury and Canadian C‑Spine Rule indicates imaging is required (CT may still be needed if X‑rays are inconclusive).
- new neck pain and aged older than 50 ys.
- HX of RA or suspicion of atlantoaxial instability.
- pain with red flags.
MRI is the investigation of choice for radiculopathy, myelopathy, suspected spinal infection and tumours.
If criteria for general practitioner access to MRI under ACC are met, arrange MRI C-Spine.
If suspicion of metastatic disease, consider bone isotope scan.
Diagnostic tips
Strains, sprains and microfractures of the facet joints, especially after a whiplash injury, are difficult to detect and are often overlooked as a cause of persistent pain.
‘One disc—one nerve root’ is a working rule for the cervical spine.
The commonest cause of neck pain is?
idiopathic dysfunction of the facet joints without a history of injury.
Red flags
Progressive or severe neurologic deficit
Fracture or dislocation
Upper cervical instability
Suspected spinal tumour
Suspected infection, including meningitis
About neck pain
It is a common condition with a lifetime prevalence of 40 to 70%.
It may be associated with headache.
Features of degenerative disease found on X-ray correlate poorly with clinical symptoms.
The evidence base for neck pain treatment is limited.
Conversion of acute to chronic neck pain is not uncommon and is more prevalent where initial pain is severe, in females, and compensation is involved.
Assess motor levels for weakness.
Level - Test
C5 - Shoulder abduction and elbow flexion
C6 - Wrist extension
C7 - Elbow extension
C8 - Flexor digitorum profundus flexion (instruct patient to bend tip of middle finger)
T1 - Finger abduction (little finger)
Spinal examination
Make a visual inspection of the neck.
Check for mid‑spine tenderness.
If no suspicion of fracture, assess range of motion.
Assess motor levels for weakness.
Check sensation with light touch and pin prick. See dermatome map.
Check biceps (C5/C6), brachioradialis (C6), and triceps (C7) reflexes.
If there is any suspicion of myelopathy (spinal cord compression), assess upper and lower limb, and urinary and bowel function.
Assess gait.
What is the Canadian C‑Spine Rule?
Follow to clinically clear cervical spine fracture without imaging.
