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Neck Pain

Dr Rajesh Varma

Traumatic neck pain

Whiplash type injury
Neck pain following sudden hyperextension, flexion, or rotation of the neck

Acute disc prolapse

Cervical strain/fracture/dislocation/myelopathy

Non-traumatic neck pain

Pain or paraesthesia radiating into the arm is not specific for nerve root pain
and may be present in people with non-specific neck pain

Simple (or non-specific)
Neck pain and/or shoulder girdle pain +/- pain referred to the arms with

  • Pain aggravated by particular movements, posture, and activities.

  • Pain radiates in a non-segmental distribution to the arm, head, shoulder, or scapulae.

  • Associated paraesthesia or hyperaesthesia, but with no objective loss of sensation or muscle strength

  • Positional asymmetry, limited range of movements often asymmetrically.

  • Tenderness in intervertebral joints and/or hypertonic muscles (palpable muscle nodules/tender bands)

Acute disc prolapse
the most common cause of severe secondary torticollis.

Acute torticollis
neck pain that is due to acute spasm with no obvious underlying cause

Cervical radiculopathy
Unilateral neck, shoulder, or arm pain that approximates to a dermatome
There may be altered sensation or numbness, or weakness in related muscle

Cervical myelopathy

Infection
herpes zoster, osteomyelitis
AbscessFever, neurologic deficit, pain

Inflammatory

Malignancy

Arthritis of the spine (spondylosis, rheumatoid arthritis)

Adverse drug reactions (for example, antipsychotic drugs, metoclopramide, amphetamines, cocaine)

Vascular
Arteriovenous malformationNumbness, paresthesias, variable pain, weakness
Thoracic outlet syndromePain, swelling, vascular insufficiency

Red Flags

Spinal cord compression
New or severe headache, photophobia or phonophobia, visual loss.
Ataxia, Gait disturbance
Clumsy or weak hands
Weakness involving more than one myotome or loss of sensation involving more than one dermatome.
Loss of sexual, bladder, or bowel function.
Babinski's sign: up-going plantar reflex, hyper-reflexia, clonus, spasticity.
Hoffman's sign.
Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs.

Spinal fracture
Severe neck tenderness

Malignancy
Lymphadenopathy
Unexplained weight loss
History of cancer

Infection
Fever, Nausea or vomiting.
Skin erythema, wounds or exudate
Infections related to substance misuse
History of tuberculosis, immunosuppression, drug abuse, AIDS, or other infections.

Inflammatory arthritis
A history of inflammatory arthritis

Other worrisome symptoms and signs
Pain that is increasing, is unremitting, or disturbs sleep.
Generalised neck stiffness.
New symptoms before the age of 20 years or after the age of 55 years.

Vascular occlusion
Vascular disease

Examination for cervical radiculopathy

  • The Spurling test — flex the neck laterally, rotate and then press on top of the person's head. The test is positive if this pressure causes the typical radicular arm pain.

  • Arm squeeze test — squeeze the middle third of the upper arm with simultaneous thumb and fingers compression (the thumb from posterior on the triceps muscle and the fingers from anterior on the biceps muscle). The test is positive when the pain score (on a 0-10 visual analogue scale) is 3 points or higher during pressure on the middle third of the upper arm compared with two other areas.

  • Axial traction — a combination of a positive Spurling test, axial traction test, and arm squeeze test increases the likelihood of cervical radiculopathy.

  • Upper limb neurodynamic tests — a combination of four neurodynamic tests and an arm squeeze test can rule out cervical radiculopathy.

Management

  1. Taking a detailed medical history and conducting a physical examination distinguish neuropathic pain from mechanical neck pain.

  2. Assess for features of specific neck conditions, for example whiplash injury, acute torticollis and cervical radiculopathy.

  3. Identifying typical features of non-specific neck pain.

  4. Excluding red flags features suggestive of a serious spinal pathology.

    Neurological symptoms and signs.

    Malaise, fever, unexplained weight loss, or unremitting pain affecting sleep.

    A history of violent trauma, neck surgery, or risk factors for osteoporosis

  5. If red flag features are present, referral (or admission) should be arranged, depending on the severity of the clinical findings.

  6. If pain <6w or subacute neck pain 6-12w
    Analgesia, topical NSAID, encourage activity, consider muscle relaxants, physiotherapy, firm pillow
    do not drive if restricted ROM

  7. Pain >12 weeks — consider referral to a pain clinic (following local referral guidelines where available)

  8. If cervical radiculopathy has been present for 4–6 weeks or more, or there are objective neurological signs:

    • Refer to confirm the diagnosis with magnetic resonance imaging (MRI), and to consider invasive procedures, such as interlaminar cervical epidural injections, transforaminal injections, or spinal surgery.

    • Indications for surgery include signs and symptoms of cervical radiculopathy, and cervical radiculopathy with unremitting radicular pain despite 6 to 12 weeks of conservative treatments, or progressive motor weakness, and MRI that shows nerve root compression.