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.
Clues to likely cause: Tumour
Ask about history of cancer or weight loss.
Pain is not relieved by bed rest, and is worse at night, often preventing sleep or waking the patient from sleep.
Pain is often exacerbated by percussion of the spinous process.
Clues to likely cause: Spinal infection
Consider epidural abscess, discitis, meningitis, osteomyelitis, dental abscess.
Increased risk if recent epidural or spinal anaesthesia, spinal surgery, or procedures with risk of bacteraemia, e.g. urological.
Suspect if fever (often absent), rigors, IV drug use, immunosuppression, variable neurological deficit (epidural abscess), midline pain on percussion.
Clues to likely cause: Rheumatoid arthritis
Hx of RA increases the possibility of atlantoaxial instability.
Atlantoaxial instability often presents with:
- unilateral sub-occipital pain.
- neurological signs, e.g. myelopathy, brainstem signs, vertigo, or lower cranial nerve palsies.
If neurological signs need urgent surgical review as there is a risk of progressive neurological deterioration and death.
Clues to likely cause: Inflammatory spondyloarthropathy
Pain may be a rare presenting feature
Consider inflammatory arthritic cause if features such as:
- onset of neck discomfort aged younger than 40 years.
- insidious onset.
- improvement with exercise.
- no improvement with rest.
- pain at night (with improvement in the morning).
Arrange CRP and HLA-B27 and plain radiology.
Be aware that radiological signs are usually delayed by 6 m or more.
Clues to likely cause: VA dissection
Can be spontaneous or post‑traumatic
Acute onset of severe, sharp neck pain
May have severe headache
Has sensation of neck stiffness but no loss of range of movement
Clues to likely cause: VBI
Vertebrobasilar insufficiency (VBI)
The vertebral artery is vulnerable:
- at the atlantoaxial junction.
- immediately before it enters the C6 foramen transversarium.
- along its course through C6 to C1 by osteophytes.
Symptoms are provoked by head position, e.g. full rotation or extension.
Symptoms:
- Ataxic gait
- Drop attacks
- Dizziness
- Diplopia
- Dysarthria
- Dysphagia
- Facial numbness
- General feeling of malaise and fatigue
- Headache
- Hearing disturbances
- Nausea
- Nystagmus
- Vomiting
Risk factors for VBI:
- Anticoagulant therapy
- Blood clotting disorders
- Cardiac or vascular disease, including stroke or transient ischaemic attack
- Diabetes mellitus
- Immediately postpartum
- Trivial head or neck trauma causing present episode
- Hypertension
- Hypercholesterolaemia or hyperlipidaemia
- Long-term use of steroids
- Previous trauma to cervical spine
- Recent infection
- Smoking
Once serious conditions are ruled out, predict the risk of
Chronic pain by assessing psychosocial risk factors.
Yellow flags are psychosocial risk factors that indicate an increased risk of developing long-term pain, distress, and disability, including work loss.
They include:
- a belief that back pain is harmful and may cause severe disability.
- fear-avoidance behaviour (avoiding a movement or activity due to anticipation of pain) and resultant reduced activity levels.
- low mood and social withdrawal.
- expectation that passive treatments rather than active participation will fix the problem.
Management
- If serious neck condition, request acute assessment:
- traumatic– Request acute orthopaedic assessment and protect spine during transfer.
- suspicion of VA or carotid artery dissection or vertebrobasilar insufficiency – Request emergency assessment.
- likely related to malignancy – Request acute oncology assessment.
- Suspected spinal infection without serious neurological deficit – Request acute general medicine assessment.
- Other serious neck concerns – Request acute surgical assessment.
- Manage other neck conditions:
- Neck pain with neurological symptoms (myelopathy, radiculopathy)
- RA – Request rheumatology advice.
- No red flags, such as cervical strain and whiplash injury, with or without radicular pain – Manage conservatively.
- Arrange review:
- If significant pain on initial presentation, review within 24 hours and reassess for serious differential diagnoses.
- If less significant pain, review in 1 to 2 weeks.
- Consider reviewing regularly until pt is functioning well and symptoms are controlled.
- If pt is recovering slowly, consider the risk of chronic neck pain and use the Örebro questionnaire.
- If symptoms present at 6 w, consider:
- X-ray, FBC, CRP, and comprehensive review following investigation results.
- musculoskeletal specialised assessment.
- occupational therapy if experiencing difficulty with everyday activities.
- work assessment and rehabilitation if experiencing difficulty with returning to work or sustaining work tasks.
- pain management for ACC pts if criteria are met.
- If chronic neck pain, see the Chronic Pain pathway.
Örebro questionnaire
Request
- If specialist care has been provided previously, refer to the same specialist.
- traumatic, orthopaedic and protect spine during transfer.
- VA or CA dissection or VBI, ED.
- malignancy, acute oncology.
- spinal infection without serious neurological deficit, acute gen medicine.
- other serious neck concerns, acute surgical.
- RA, rheumatology.
- Consider referral to physiotherapy.
- If symptoms present at 6 w despite conservative management, consider:
- musculoskeletal specialised assessment.
- occupational therapy.
- work assessment and rehabilitation.
Neck pain exercises video
Patient, HealthInfo – Neck Pain
