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Identifying the Musculoskeletal Causes of Neck Pain

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Identifying the Musculoskeletal Causes of Neck Pain
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  302 Medical Progress September 2012 GENERAL MEDICINE Neck pain is a common problem. This article discusses the diagnosis and management of the musculoskeletal causes of neck pain, with emphasis on the neurological impairment and accompanying signs elicited by provocative manoeuvres during the evaluation of neck pain. Identifying the Musculoskeletal Causes of Neck Pain Bernard M Karnath , MD N eck pain, or cervicalgia, is a common problem; about two-thirds of persons in the US population have neck pain at some point in their lives. 1  The diagnosis of neck pain most often can be made  with the history and physical examination. However, care must be taken to evaluate for ‘red flag’ symptoms, including intractable pain, fever, gait disturbance, and exquisite tenderness over a vertebral body, as signs of serious con-ditions. 1  Although the reasons for neck pain may be complex, most neck pain is caused by local mechanical problems. 2  Mechanical neck pain results from damage to the joints, disks, or soft tissue. Degenerative disk disease and cervical facet arthropathy are common mechanical causes of neck pain; muscle- and ligament-related injuries resulting from trauma or strenuous activity are others. Provocative manoeuvres are helpful in the evaluation of neck pain because they are used to aggravate or relieve symptoms with the neck in various positions.In this article, I discuss diagnosis and man-agement of the musculoskeletal causes of neck pain. I emphasize neurological impairment and the accompanying signs elicited by provocative manoeuvres. Most neck pain is caused by local mechanical problems.  Medical Progress September 2012 303 GENERAL MEDICINE Clinical Evaluation  The time frame for evaluation is important because acute neck pain most often is caused by trauma, whereas degenerative changes lead to chronic neck pain. 3  Acute neck pain has a time frame of less than 3 weeks, and chronic neck pain is defined by a duration of 12 or more weeks; subacute neck pain falls in between. 4  Degenerative changes are slow to develop, but injuries (eg, herniated disks) are likely to cause acute neck pain. 3 Physical Examination  The physical examination begins with careful inspection of the neck. The examiner should take note of any masses or asymmetries. Palpation, performed with the fingertips, includes evaluation of the thyroid gland, lymph nodes, muscles, and soft tissues.Passive range of motion is assessed in three planes—flexion-extension; left-right rotation; and left-right flexion, or lateral bending. Most mechanical neck problems are asymmetrical, and passive range of motion may be limited asymmetrically by pain. 2 Provocative Testing  Along with testing of sensation, strength, and reflexes, several pro- vocative manoeuvres are useful in evaluating cervical radiculopathy. Neck pain may radiate into the extremities, and it may be worsened by these  various provocative manoeuvres. Pro- vocative tests place the neck and arm in  various positions to aggravate or relieve symptoms. Provocative manoeuvres and their resulting signs include the Spurling, Lhermitte, shoulder abduction, Adson, and Hoffmann signs.  Red Flag Symptoms Noting the presence of red flag symptoms, such as intractable pain, fever, night sweats, unexpected weight loss, and gait disturbance, helps cli-nicians identify malignancy, infection, and other potentially serious diagnoses. Exquisite tenderness over a vertebral body is concerning for malignancy or compression fracture. When point ten-derness occurs in the setting of fever, infection is a strong possibility.Cervical osteomyelitis is a potential diagnosis in a patient who has fever and neck pain. 5  Magenetic resonance imaging (MRI) evaluation along with blood cultures and an erythrocyte sedimentation rate help confirm this diagnosis. 5 Other Testing and Imaging Electromyography and nerve con-duction velocity studies are useful in determining which nerve is affected and An MRI scan can be used to assess structural changes of the disk. The time frame for evaluation is important because acute neck pain most often is caused by trauma, whereas degenerative changes lead to chronic neck pain   304 Medical Progress September 2012 GENERAL MEDICINE the location of the compression. These studies help differentiate a cervical radiculopathy from an entrapment neuropathy, such as ulnar or median neuropathy. An MRI scan of the spine is most useful in evaluating a patient  with cervical radiculopathy to confirm the actual cause of the radicular pain. In addition, an MRI scan can be used to assess structural changes of the disk. Intra-articular anaesthetic injections  with fluoroscopic guidance also may help confirm other causes of neck pain, such as facet joint arthropathy. 6 Neck Pain Disorders Cervical Spondylosis  This condition, the result of degen-erative changes as a natural consequence of aging, may cause axial neck pain, radiculopathy, myelopathy, or a combination of these problems. 7  Degenerative changes result in osteophyte formation, 1  and osteophytes can impinge on adjacent structures. The diagnosis of cervical spon-dylosis usually is made by clinical evaluation alone. 1  Presenting features include neck pain aggravated by movement, poorly localized ten-derness, limited range of movement, and vague paraesthesias of the upper extremity. 1 Axial Neck Pain  This is the most common cause of neck pain. Lesions of the upper cervical nerve roots (C2-4) are uncommon and give rise to no motor deficits. 3,8  Sensory involvement is as follows:           The C2-3 facet joints may be the source of occipital, or cervicogenic, headache. 2,9  The C2-4 nerve roots are not associated with motor involvement.  Axial neck pain may radiate to the shoulders and head. 7  In the absence of radicular symptoms, determining the source of the neck pain can present a diagnostic challenge. 7 Cervical Radiculopathy Eight pairs of cervical nerve roots srcinate from the spinal cord (Figure). Each cervical nerve root exits above the corresponding vertebra, except for the eighth nerve root, which exits above the first thoracic vertebra. The brachial plexus is composed of nerve roots from the first thoracic and the lower four cervical levels (C5-T1).  The nerve roots of C5 and C6 join to form the upper trunk; those of C8-T1 join to form the lower trunk. The nerve root of C7 alone makes up the middle Table 1. Distribution of cervical radiculopathy Disk spaceNerve rootMuscleReflexSensory C4-5C5Deltoid, supraspinatus, infraspinatusBicepsLateral armC5-6C6     Biceps, brachioradialisRadial forearm, thumb,   C6-7C7       TricepsMiddle fingerC7-T1C8    NoneFourth and fifth fingersT1-2T1Finger abductorsNoneUlnar forearm Figure. Several anatomical sources of chronic neck pain are shown in this transverse section. Seven vertebrae and eight cervical nerves make up the cervical spine. Conditions that frequently affect the neck and cause pain include degenerative arthritis, cervical radiculopathy, cervical disk herniation, and myelopathy.  Medical Progress September 2012 305 GENERAL MEDICINE trunk. Several anatomical sources of chronic neck pain are shown in this transverse sectionCompression at the nerve root level (eg, herniated disk) produces specific dermatomal symptoms (Table 1). Thoracic outlet syndrome (TOS), peripheral entrapment neuropathies, and other conditions have overlapping dermatomes.Disk herniations may occur suddenly; nerve root compression related to spondylosis may develop slowly. 3  Herniation of an intervertebral disk may be caused by degenerative processes or trauma. 3  Disk herniations may occur centrally or laterally. Central disk herniations may compress the cervical cord directly; lateral disk her-niations result in compression of a cervical nerve root. 3 Physical findings for cervical radic-ulopathy, a neurological condition characterized by pain in the neck and arm, include a combination of deficits in motor function, sensation, and reflexes. 3,10  The disorder typically is caused by degenerative changes that result in foraminal encroachment. Radiculopathy resulting from nerve root compression usually occurs at the C5-7 level; the C7 nerve root is most frequently involved. 1  Cervical radic-ulopathy typically manifests as pain radiating from the neck into the dis-tribution of the affected nerve root. 8  Sensory symptoms are more common than weakness. 1  The diagnosis of cervical radicu-lopathy most often can be made  with the history and physical exami-nation. There are no clear guidelines on when imaging is warranted. 10  Red flag symptoms would justify imaging, as would neurological deficits. 10  Nerve conduction studies could help differ-entiate cervical radiculopathy from a compressive peripheral entrapment neuropathy (eg, carpal tunnel syndrome [CTS]). The Spurling test may be used to evaluate patients for cervical radicu-lopathy (Table 2). The sign is elicited by extending, rotating, and laterally flexing the patient’s neck toward the symptomatic side. Then, the examiner applies axial pressure on the spine. Pressure applied on top of the head may intensify symptoms. The Spurling test has a sensitivity of 30% to 60% and a specificity of 90% to 100%, 10–13  quite similar to those of other provocative manoeuvres (low sensitivity but high specificity).  Therefore, this test is not useful as a screening tool, but it does help confirm the diagnosis of cervical radic-ulopathy. 11  The Lhermitte sign is performed by having the patient flex his or her neck forward. An electric shock–like sensation radiating down the spine and into both arms is considered a positive test result. 14  The sign also may provoke paraesthesias in the lower extremities. 2  The Lhermitte sign suggests a lesion of the dorsal columns of the cervical cord that can be caused by several conditions that affect the cervical spine. The sign most often is asso-ciated with multiple sclerosis (MS), being present in up to 41% of patients  who have definite MS, 15  but it may present in other conditions, such as radiation myelopathy, herpes zoster, and subacute combined degeneration resulting from vitamin B 12  defi-ciency. 14,16,17 Other signs and manoeuvres to consider in the evaluation of possible cervical radiculopathy include the arm abduction sign and manual traction. The shoulder abduction sign is performed by resting the patient’s abducted arm on top of his forehead  with the elbow flexed. 18  Pain relief  with the arm in this position is a positive finding.Manual traction of the neck, or the neck distraction test, also may result in pain relief. 12  To perform this manoeuvre, the examiner grasps the Table 2. Provocative testing in the evaluation of neck pain Sign Technique Diagnosis Spurling         toward the symptomatic side; look for     Cervical radiculopathy (eg, herniated disk)AdsonElicited by having the patient elevate the chin and rotate the head toward the affected side while inspiring deeply; look for obliteration of the radial pulse on the affected sideThoracic outlet syndromeHoffmannElicited by firmly grasping the middle finger and quickly snapping or flipping the dorsal              Cervical myelopathy (eg, cervical spinal stenosis) Cervical radiculopathy typically manifests as pain radiating from the neck into the distribution of the affected nerve root
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