Neck Pain

1. In patients with non-traumatic neck pain, use a focused history, physical examination and appropriate investigations to distinguish serious, non-musculoskeletal causes (e.g., lymphoma, carotid dissection), including those referred to the neck (e.g., myocardial infarction, pseudotumour cerebri) from other non-serious causes.
2. In patients with non-traumatic neck pain, distinguish by history and physical examination, those attributable to nerve or spinal cord compression from those due to other mechanical causes (e.g., muscular).
3. Use a multi-modal (e.g., physiotherapy, chiropractic, acupuncture, massage) approach to treatment of patients with chronic neck pain (e.g., degenerative disc disease +/- soft neuro signs).
4. In patients with neck pain following injury, distinguish by history and physical examination, those requiring an X-ray to rule out a fracture from those who do not require an X-ray (e.g., current guideline/C-spine rules).
5. When reviewing neck X-rays of patients with traumatic neck pain, be sure all vertebrae are visualized adequately.

General Overview

• Temporal
  • Acute <6w
  • Subacute 6w-6mo
  • Chronic >6mo
• Origin
  • Axial Neck Pain Syndromes
    • Cervical strain
    • Cervical spondylosis
    • Cervical discogenic pain
    • Cervical facet syndrome
      • Whiplash injury
    • Cervical myofascial pain
    • Diffuse skeletal hyperostosis
  • Extremity pain/neurological deficit
    • Cervical spondylotic myelopathy
    • Cervical radiculopathy
    • Brachial plexus injury (eg. burner/stinger)
  • Non-spinal
    • Thoracic outlet syndrome
    • Herpes Zoster
    • Diabetic neuropathy
    • Other (Malignancy, vascular, cardiovascular -MI, carotid/basilar artery dissection, infection, visceral, referred, rheumatologic, neurologic)

Red Flags

• Trauma
• Cancer or constitutional symptoms
• Infectious symptoms, Immunosuppression or IVDU (Epidural abscess, discitis)
• Neurological signs/symptoms (cord compression, demyelinating process)
• Severe ripping neck pain, unstable (carotid/vertebral dissection)
• Chest pain, SOB, diaphoresis (MI)
• History of rheumatoid arthritis (atlanto-axial disruption)

Physical Exam

• Neck
  • Observation - posture, symmetry, muscle bulk, scars
  • ROM in all planes
  • Palpation of cervical spine, r/o focal tenderness
    • Palpation of trapezius and paraspinal muscles
    • Lymphadenopathy
  • Neurological examination of upper limbs (strength, sensory, reflex)
    • C1, C2 - Neck flexion
    • C3 - Neck lateral flexion
    • C4 - Shoulder elevation (Trapezius)
    • C5 - Shoulder abduction/external rotation, bicep reflex
    • C6 - Biceps/brachioradialis reflex
    • C7 - Triceps reflex
    • C8 - Finger abduction, grip
    • T1 - Hand intrinsics
  • Provocative manoeuvres (not sensitive)
    • Spurling (cervical root compression)
      • Head flexed, ipsilaterally rotated and tilted, with axial loading
    • Upper limb tension test (equivalent of straight leg raise for arm)
      • Wrist supinated, shouder abducted, elbow extended, and neck lat flexion to contralateral side
    • Manual neck distraction test
      • Vertical traction on head - and pain relieved
• Examine shoulder

Clear C-spine Injury

• Consider NEXUS criteria (caution using criteria in <2yo, and>65yo)
  • Neuro deficit (focal)
  • Spinal (midline) tenderness
  • Altered LOC
  • Intoxication
  • Distracting injury
    • There is some data showing that you may consider clearing C-spine even in distracting injury
• Consider Canadian C-Spine Rule in alert, stable trauma patients (excluded known spine disease/surgery, non-trauma, GCS<15, age <16 years - consider NEXUS)
  • Can clear C-spine if no high risk factor:
    • Age ≥ 65 years
    • Extremity paresthesias
    • Dangerous mechanism (Fall ≥3 ft/5 stairs, axial load to head [eg. diving], MVC >100km/h or rollover or ejection, motorized recreational vehicles, bicycle crash)
  • One low risk factor present AND able to actively rotate neck 45° left and right:
    • Sitting position in the ED
    • Ambulatory at any time
    • Delayed (not immediate onset) neck pain
    • No mid-line tenderness
    • Simple rear-end motor vehicle collision

Imaging

• Blunt Trauma
  • Lateral, AP, odontoid X-ray
    • High risk mechanism
    • Multiple system trauma with comorbid injuries to head, face, torso
    • Conditions that predispose C-spine injury (Down syndrome)
    • AMS (GCS 14)
    • Neck pain, tenderness, deformity, limited ROM
  • Flexion-extension X-ray
    • Normal C-spine X-ray and no neuro deficit, continued pain/tenderness, and able to flex and extend neck
  • CT C-spine
    • Acute neuro deficit
    • GCS 3-13
    • Abnormal/suspicious C-spine X-ray
  • MRI if abnormal neurological exam and if requires spinal cord imaging
• Consider initial five-view X-ray (odontoid, lateral, PA, and both oblique views) in non-traumatic neck pain if
  • Age >50yo with new symptoms
  • Constitutional symptoms
  • History of malignancy
  • Moderate-severe pain >6w
  • Progressive neurological findings
  • Infectious risk
• Not required in cervical radiculopathy (motor/sensory/reflex deficits) UNLESS (consider MRI)
  • Trauma
  • Persistent symptoms >4-6w of treatment
  • Red flag (malignancy, myelopathy, abscess)
• MRI in all progressive neurological deficits, suspicion of infection/malignancy, or significant pain >6w
• Consider EMG if pain and dysesthesia in extremities

Treatment

• Early return to usual activities
  • Home exercises
  • Soft collar not recommended (unless few days)
• Tylenol, NSAIDs, muscle relaxant for initial 4 days
• Second-line
  • Manual Physiotherapy
    • Consider multimodal (physiotherapy, chiropractic, acupuncture, massage) for chronic neck pain
  • Augment pain control
    • Tramadol
    • TCA, Venlafaxine
• Refer Physiotherapy / Neurosurgery / Neurology