Neck Pain¶
Samir Khan
Background¶
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Most common cause of neck pain in adults: degenerative changes of the cervical spine
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Most atraumatic neck pain does not require imaging
Presentation¶
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Cervical muscle strain: pain + stiffness with movement 2/2 muscular injury
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Degenerative disc disease/osteoarthritis: pain + stiffness with movement from derangement in disc architecture leads to inability to distribute pressure in the joint
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Cervical radiculopathy: neuropathic pain, sensory abnormalities, and/or weakness in an upper extremity (often radiating to hand)
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Cervical myelopathy: spinal cord compression causing neurologic dysfunction
- Earliest symptom is gait disturbance. Pain is uncommon
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Non-cervical conditions: shoulder pathology, migraine/headaches, occipital neuralgia, torticollis, thoracic outlet syndrome, angina pectoris/MI, bony metastases, vertebral artery or carotid artery dissection, fibromyalgia, meningitis, transverse myelitis
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Posterior neck pain
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Axial only à MSK (sprain vs degenerative disc disease)
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Axial + Extremity Pain Radiculopathy
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Anterior neck pain
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Common sources: esophageal, thyroiditis, carotidynia, lymphadenitis, Ludwig’s angina
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Red flags: recent trauma, lower extremity weakness, gait abnormality, bowel/bladder incontinence, fever, weight loss
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Evaluation¶
- Determine MSK (axial pain) vs Radiculopathy/Myelopathy vs Non-spinal
| Provocation Tests of the Neck | |||
|---|---|---|---|
| Test | Isolates | Action | Positive if |
| Spurling’s test | Cervical radiculopathy | Downward pressure applied to top of head with extended neck and rotates to affected side | Reproducible pain beyond shoulder Neck pain alone is not specific |
Elvey's upper limb tension test |
Cervical radiculopathy | Head turn contralaterally, arm is abducted while the elbow extended | Reproduction of symptoms |
| Hoffman sign | Corticospinal lesion (UMN) | Loosely hold middle finger and flick the fingernail downward, allowing the middle finger to flick upward reflexively | There is flexion & adduction of thumb/index finger on the same hand |
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Imaging indications: Neuro deficits, Red flags, persistent pain (> 6 weeks)
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Cervical Plain films, 2-view (AP and lateral)
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Cervical MRI: visualizes spinal cord, nerve roots, bone marrow, discs and soft tissues
- Usually w/o contrast; can consider contrast if malignancy or infection suspected
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EMG/Nerve Conduction Studies: not routinely used for neck pain evaluation, but can be used to distinguish cervical radicular pain from peripheral causes of extremity dysesthesia
Management¶
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Cervical strain, Cervical radiculopathy: PT
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5 d course of oral prednisone 60-80 mg, followed by 7-14 day taper
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Anti-spasmodic prn: Flexeril or Robaxin
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If not improving or progressive symptoms refer to Ortho Spine + PM&R
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Cervical myelopathy requires urgent surgical evaluation