Neck Pain
Nachii Narasinghan
Introduction
• F>M
• Highest prevalence in middle age
• Types
– Non-specific
– Whiplash
– Cervical spondylosis
– Acute torticollis
Assessing neck pain
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Exclude non-MSK causes
Assess for red flags
Assess range of neck movements
Perform a neuro exam
Identify risk factors for developing neck pain
Identify psychosocial factors that may
suggest increased risk for chronicity and
disability
• The negative predictive value of these ‘red
flags’ clinical findings is high;
– if no ‘red flags’ are present, then it is unlikely
that a serious spinal abnormality has been
missed.
• Individual positive findings must be
interpreted with care, as their positive
predictive value for diagnosing serious
disease is poor (Williams and Hoving,
2004)
Red Flags
• 'Red flags' that suggest cancer, infection, or
inflammation:
– Malaise, fever, unexplained weight loss.
– Pain that is increasing, is unremitting, or disturbs sleep.
– History of inflammatory arthritis, cancer, tuberculosis,
immunosuppression, drug abuse, AIDS, or other infection.
– Lymphadenopathy.
– Exquisite localized tenderness over a vertebral body.
• 'Red flags' that suggest severe trauma or skeletal
injury:
– A history of violent trauma (e.g. a road traffic accident) or a fall from a
height. However, minor trauma may fracture the spine in people with
osteoporosis.
– A history of neck surgery.
– Risk factors for osteoporosis: premature menopause, use of systemic
steroids.
• 'Red flags' that suggest vascular
insufficiency:
– Dizziness and blackouts (restriction of vertebral artery)
on movement, especially extension of the neck when
gazing upwards.
– Drop attacks.
• 'Red flags' that suggest compression of the
spinal cord (myelopathy):
– Insidious progression.
– Neurological symptoms
• gait disturbance, clumsy or weak hands, or loss of sexual, bladder, or
bowel function.
– Neurological signs:
• Lhermitte's sign: flexion of the neck causes an electric shock-type
sensation that radiates down the spine and into the limbs.
• UMN signs in the lower limbs (Babinski's sign — up-going plantar
reflex, hyperreflexia, clonus, spasticity).
• LMN signs in the upper limbs (atrophy, hyporeflexia).
• Sensory changes are variable, with loss of vibration and joint position
sense more evident in the hands than in the feet.
Investigations
• Cervical x-rays and other imaging are not
routinely required in the dx or assessment
of neck pain with radiculopathy or nonspecific neck pain.
• Best to be open about limitations of
investigations and reassure patients that
they can be helped without such
investigations.
What should be done with patients with neck
pain? (x-ray shows cervical spondylosis)
• Degenerative changes affecting C-spine
discs and facet joints
• Depends on clinical
picture
• Abnormal neurology, or persistent or progressive
brachialgia with or without abnormal neurology, warrants
neurosurgical investigation
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Surgery is good at reducing compressive nerve root
symptoms and signs and arresting myelopathic
progression.
• Surgery is less good at reducing myelopathic symptoms
and signs when these are chronic
• Urgency of referral depends on the severity of
neurological deficit and rate of progression.
Basis for recommendation
• In the absence of ‘red flags’ plain X-rays of the
cervical spine are unlikely to help and may lead
to false-positive findings (Williams and Hoving).
• Features of degenerative disease are also
common in asymptomatic people older than 30
years of age and correlate poorly with clinical
symptoms. (Binder,2007).
Neck pain
• Acute (3-4 weeks)
• Sub-acute (4-12 weeks)
• Chronic
Acute neck pain
• Encourage the patient to:
– remain as active as possible
– restore their neck movements as pain allows
– correct poor posture if precipitating or
aggravating the neck pain
– sleep with one pillow which provides lateral
– support and also gives support to the hollow
of the neck. Two pillows may force the head
into an unnatural position.
• Discourage the patient from:
– prolonged absence from work
– wearing a cervical collar (which may hinder
recovery).
Sub acute neck pain
• Refer to physiotherapy for a multimodal treatment
– strategy that includes postural advice, exercises and
manual therapy.
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Acupuncture may be included at this stage.
Promote positive attitudes to activity and work.
Address any psychosocial factors
Consider referral to a psychologist or
occupational health clinician.
Chronic neck pain
• Continue physiotherapy if it is helping,
discontinue if not.
• Avoid passive interventions, e.g.
electrotherapy and massage.
• Reassess psychological factors.
• Consider referral to a pain clinic for people
with chronic pain or nerve root symptoms
where there is poor control.
Take home messages
• Be aware of red flags in the assessment of
neck pain.
• Mainstay of the initial management of
simple neck pain is conservative and in
primary care.
• Role of imaging is limited.
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Thank you