21. | Manual of Rheumatology and Outpatient Orthopedic Disorders (LB Spiral Manuals)

Chapter 14 Neck Pain

Manual of Rheumatology and Outpatient Orthopedic Disorders

Chapter 14 Neck Pain

Thomas P. Sculco and Alexander Miric

Anatomic considerations
History
Physical examination
Laboratory studies
Differential diagnosis
Therapy

I. Anatomic considerations. The cervical area is composed of an integrated complex of structures whose dysfunction singly or in combination can result in neck or radicular pain. These structures include the following:

Vertebrae.
Intervertebral disks.
Apophyseal and uncovertebral joints.
Vertebral arteries.
Spinal cord and nerve roots.
Ligamentous complex.
1. Anterior and posterior longitudinal ligaments.
2. Interspinous and supraspinous ligaments.
Paracervical musculature.

II. History

Mode of onset
1. A history of neck trauma may allow one to localize the injured structures and increases the probability that cervical films will reveal the injury .
2. If unrelated to trauma, acute severe restriction of motion can indicate paracervical muscle spasm ( wry neck ).
3. If symptoms are more chronic in nature and began after frequent neck rotation, neck pain can indicate cervical disk degeneration and osteoarthritis .
Duration and localization of pain
1. Acute onset of pain usually suggests muscle spasm or nerve root irritation; radiation to the occiput or interscapular area may suggest a nerve root lesion.
2. Chronic neck pain that occurs intermittently with or without radicular symptoms may be seen in cervical osteoarthritis.
3. If radiculitis is severe, pain radiation to the shoulder and arm indicates nerve root compression resulting from either a disk herniation or foraminal encroachment by the osteophytes associated with osteoarthritis.
4. Shoulder pain either may be a radicular symptom secondary to root compression or may represent primary pain with associated referred neck and trapezial pain.
Relief and aggravation of pain. Rest in the supine position usually relieves local neck pain produced by muscle spasm but may have little or no effect on processes primarily involving osseous or ligamentous structures.
Neurologic signs and symptoms
1. Paresthesias radiating from the neck to the arm are an important indicator of nerve root irritability as the origin of the pain.
2. Numbness and weakness of the arm or hand indicate more severe nerve root compromise; careful neurologic examination will often localize the cervical nerve root involved (see Appendix B).
3. Patients with vertebral artery compromise may complain of dizziness, visual dysfunction, and syncopal episodes .
4. Cervical myelopathy can be identified in cases of severe cervical osteoarthritis; patient complaints may range from mild to severe difficulty with ambulation or handling objects.
Past medical history should be thoroughly explored. A history of malignancy, previous neck problems, associated musculoskeletal disorders, metabolic bone diseases, and smoking habits should be pursued. Patients with a history of rheumatoid arthritis often exhibit signs and symptoms of C1 “2 instability. Patients with a history of psoriatic arthritis, ankylosing spondylitis, severe rheumatoid arthritis, or juvenile rheumatoid arthritis also often have associated cervical pathology. A history of intravenous drug abuse or a compromised immune system increases the chance of an infectious process. Because myocardial ischemia and aortic disease can present as neck pain, a complete medical history is needed.
The occupational history may provide the inciting cause of pain. Patients who perform extensive overhead work, such as painting or hanging wallpaper, may have increased pain after work. Patients with work- related symptoms often require longer periods of therapy.

III. Physical examination. The patient should disrobe sufficiently to allow full visualization of the neck and thoracic spine.

Patient standing
1. Observe the position in which the neck is held. With severe unilateral paracervical spasm, the head may be flexed laterally to that side and rotated to the opposite side.
2. Severe paracervical muscle spasm can be visualized and palpated posteriorly.
3. Evaluate the presence of neck or paracervical muscle atrophy. Also compare trapezial and shoulder musculature symmetry.
4. Examine shoulder strength and range of motion, and palpate for localized shoulder tenderness in an effort to rule out shoulder pathology as the source of pain.
Patient sitting
1. Record active and passive neck range of motion.
  1. Normal flexion ends with the chin against the chest.
  2. Normal extension ends with the occiput near C-7.
  3. Normal rotation approaches 70 degrees to each side.
  4. Normal lateral bending approaches 50 to 60 degrees.
2. Examine for supraclavicular lymphadenopathy and carotid artery pulses .
3. Perform a neurologic examination of the upper extremities.
  1. Sensory examination with pin and cotton ball as well as tuning fork.
  2. Motor testing, particularly of deltoid, biceps, triceps, wrist flexors and extensors, finger flexors and extensors, and interossei.
  3. Reflex examination should include biceps, triceps, and brachioradialis.
Patient prone, forehead on pillow
1. Palpate paracervical area and spinous process for specific areas of tenderness or trigger points.
2. Evaluate deep percussion sensitivity in interscapular area.

IV. Laboratory studies

Radiographs, when needed, should be taken in anteroposterior, oblique , and lateral views. These films may be supplemented with an open -mouth view of the odontoid or flexion-extension films when instability is suspected. In cases of mild neck pain, a therapeutic trial for osteoarthritis might be tried before radiography is ordered. As symptoms and signs worsen, radiographic procedures become more appropriate.
1. Alignment of the spine in the anteroposterior and lateral projections should be evaluated.
  1. The anteroposterior film should reveal approximately the same distance between spinous processes.
  2. The lateral film should reveal vertebral bodies forming a gentle curve that is concave posteriorly.
2. Narrowing of the disk space is best seen on the lateral view. Such narrowing is most commonly seen at the C5 “6 level, followed by the C6 “7 and C4 “5 levels.
3. The oblique view should demonstrate neural foramina of relatively uniform size through which the cervical nerve roots traverse. Isolated narrowing or the presence of an osteophyte may sometimes be identified.
4. The uncovertebral joints (joints of Luschka) are best seen on the anteroposterior view; cervical osteoarthritis often leads to narrowing of these joints.
5. The presence of a cervical rib should be noted as well.
6. Congenital fusions of cervical vertebrae or other bony anomalies may be present.
Further diagnostic studies
1. Magnetic resonance imaging is an excellent way to visualize the spinal cord and soft tissues in relation to bony anatomy.
2. Computed tomography is useful in determining spinal stenosis and areas of nerve root compression by osteophytes.
3. Myelography is indicated in patients with intractable neck pain and radiculopathy to localize spinal cord or nerve root compromise by disk, osteophyte, neoplasm, or other space-occupying process. Originally used in conjunction with plane radiographs, myelography is now often performed along with computed tomography in an effort to visualize the canal better (see section IV. B.2 ).
4. Bone scan may demonstrate osseous involvement by neoplasm, vertebral compression fracture, or infection in the cervical spine.
5. Electromyography may be useful in demonstrating spinal stenosis and areas of nerve root compression by osteophytes.
6. Standard blood work may reveal abnormal values, such as an elevated white blood cell count, erythrocyte sedimentation rate, or serum glucose level (in diabetic patients), that suggest an infectious process.

V. Differential diagnosis

Neck pain without radiculopathy. Referral to the occiput and upper back may or may not be present.
1. Vertebrae
  1. Fracture, traumatic or osteoporotic (rare).
  2. Septic spondylitis.
  3. Tumor.
    1. More likely to be primary if patient is young (<20 years ).
    2. More likely to be metastatic if patient is older (>50 years).
2. Intervertebral disk
  1. Herniated cervical disk.
  2. Disk space infection is rare in the cervical area but may present with severe neck pain and torticollis.
  3. Disk degeneration.
3. Apophyseal and uncovertebral joints
  1. Osteoarthritis.
  2. Rheumatoid arthritis may lead to destruction of these joints with resultant pain and instability, particularly at the C1 “2 level.
4. Soft tissues
  1. Ligamentous injury to the neck results in pain and cervical instability.
  2. Acute muscular spasm can produce acute pain and torticollis ( wry neck ). Wry neck may arise after trauma (e.g., whiplash), prolonged exposure to cold, prolonged period in an awkward position, or other activities that strain and require considerable neck rotation or positioning.
  3. Polymyalgia rheumatica may lead to neck and shoulder pain in an elderly patient with systemic complaints or headache .
  4. Tension and anxiety can produce severe paracervical muscle spasm.
5. Surrounding structures. Neck pain may be referred from the shoulder or periscapular structures. Cervical lymphadenopathy, if painful, can produce severe restriction in neck motion. Occipital headaches may produce secondary neck pain and muscle spasm. In addition, trigeminal and glossopharyngeal neuralgias have been described to cause neck pain.
Neck pain with radiculopathy. Objective neurologic deficit may or may not be present.
1. Vertebrae. Tumors or infections may produce radicular signs and symptoms.
2. Intervertebral disk. Herniation or degeneration of an intervertebral disk may produce specific radicular patterns, depending on the level of involvement. Considerable overlap exists among the patterns outlined below. C5 “6 and C6 “7 are far more commonly involved than C7-T1 or C4 “5.
  1. C5 “6 (C-6 nerve root). Pain will radiate to the shoulder or lateral arm and dorsal forearm. Anesthesia and paresthesias may be present in the thumb and index finger. Weakness, if present, will involve the biceps and wrist extensors. The biceps reflex is often decreased or absent.
  2. C6 “7 (C-7 nerve root). The pain distribution is similar to that of a C-6 radiculopathy. Anesthesia and paresthesias, when present, involve the index and long fingers. Weakness, if present, is noted in the triceps, wrist flexors, and finger extensors. The triceps reflex is often decreased or absent.
  3. C7-T1 (C-8 nerve root). Pain may occur along the medial aspect of the upper arm and forearm. Anesthesia and paresthesias involve the ring and small fingers. Weakness, if present, is noted in the finger flexors and intrinsic musculature of the hand. The triceps reflex may be reduced.
3. Apophyseal and uncovertebral joints. Degenerative arthritis affecting these joints in the cervical area can lead to secondary encroachment of the cervical intervertebral foramina with nerve root irritation.
4. Surrounding structures
  1. Thoracic outlet syndrome. Radicular symptoms with or without neurologic deficit can occur with compression of the subclavian vessel by a cervical rib or tight scalenus anterior muscle.
  2. Brachial plexus injuries can lead to marked neurologic deficits with retrograde pain to the cervical area.
  3. Pancoast tumors of the lung apex may occasionally produce neck pain and neurologic deficits.
  4. Visceral disease with referred pain can originate in the aorta, the heart, or the lung.

VI. Therapy

Rest is the cornerstone of therapy for patients with neck pain, whether or not radiculopathy is present.
1. The patient should be advised to avoid activities that are particularly stressful to the neck; examples are driving, overhead lifting , athletic activities such as golf and tennis, and sitting at a desk for prolonged periods reviewing written material or working at a computer.
2. The neck should be supported by a firm cervical collar, fitted so that cervical motion is limited 60% to 70% and the patient is comfortable. The collar should be worn full-time initially; as symptoms recede, the patient may be weaned from the collar. Soft foam collars provide little, if any, cervical immobilization but may be useful during sleep if the firm collar is uncomfortable.
3. Neck pain is usually worse at night because of the positioning during sleep. Avoidance of more than one small pillow or the use of a cervical pillow often helps to decrease pain and spasm.
Moist heat generally relaxes tight, spastic musculature. A moist, warm towel can be wrapped around the neck as a collar; as the towel cools, this action can be repeated. A hydroculator or a hot water bottle wrapped in a moist towel can also be used.
Medications may be useful depending on the origin of the neck pain.
1. If there is inflammation or cervical radiculitis, 650 to 975 mg of aspirin PO four times daily or other nonsteroidal antiinflammatory drugs may help decrease inflammation and relieve pain provided the patient is at low risk for gastrointestinal bleeding.
2. If pain is severe, 60 mg of codeine PO q4h is used as needed.
3. Muscle relaxants, such as Flexeril, may aid in relief of paracervical muscle spasm. Powerful medications such as codeine and muscle relaxants should be used to manage acute, severe pain and not to treat chronic pain syndromes.
Physical therapy is useful if an osseous spur is compromising the intervertebral foramina to cause nerve root entrapment.
1. Three to five sessions per week of intermittent cervical traction, each lasting 20 to 30 minutes and reaching a maximum of 20 to 35 lb, may be used.
2. Traction may be preceded by ultrasound or diathermy to the upper neck and upper back.
3. If pain is severe, travel to the therapy center should be minimized. For these patients, home cervical traction may be prescribed.
4. Patients who improve during supervised cervical traction should also obtain home traction units for use twice daily. The length of the sessions should be gradually decreased as symptoms resolve.
Exercises should be encouraged only if they do not exacerbate the pain. Active range of motion can easily be performed in a shower or sauna. As the patient improves , isometric exercises in various positions of neck rotation and lateral bending may be prescribed (see Chapter 56). If weakness remains after cervical pain has diminished, exercises performed while swimming in a pool may prove useful.
Surgery rarely is needed. However, in the setting of refractory pain or neurologic deficits unresponsive to a conservative regimen, it may be considered .

Books@Ovid
Copyright 2000 by Lippincott Williams & Wilkins
Stephen A. Paget, M.D., Allan Gibofsky, M.D., J.D. and John F. Beary, III, M.D.
Manual of Rheumatology and Outpatient Orthopedic Disorders

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