Neck Pain
Elise M. Coletta and Meredith A. Goodwin
Approach
The differential diagnosis for neck pain can be thought of by pattern of onset (Table 12.8). Disease, which can originate in the neck, can be felt there or elsewhere. The neck is also a site of referred pain.
History
A. General. Patient age and occupation are important. An individual’s job can involve awkward or prolonged body positioning (1). Some of the conditions listed in Table 12.8 can present with fever or with constitutional or other musculoskeletal symptoms. More diagnosis-specific symptoms may be present (e.g., chest pain with a myocardial infarction).
B. Pain characteristics. What is the character, location, frequency, and duration of pain? Tumors of the cervical spine can present with unremitting neck pain that is worse at night. Referred neck pain from intrathoracic pathology is more often located anteriorly.
C. Precipitating factors. Any prior history of neck problems? Has there been any preceding neck trauma or change in work or avocational activities? A history of collision trauma may warrant consideration of concurrent head injury. Is there any relationship of the pain to a particular neck position or movement? Careful questioning may be needed to uncover this latter information, but it is crucial to determining the mechanism of pain production. Have there been any emotional stressors?
D. Associated symptoms. Is headache present? Any paresthesia, dyskinesia, or weakness of the trunk or upper or lower extremities? Bladder dysfunction can occur with a central spinal cord injury. What is the distribution of any radicular pain? An increase in radicular symptoms with coughing or sneezing suggests nerve root impingement (2).
Physical examination
A. General. After any cervical spine injury, order an x-ray study first to rule out an unstable injury. Assess gait, which can be impaired with a cervical myelopathy. Notice neck posture (3). Torticollis can occur secondary to trauma, muscle strain, vertebral subluxation, viral infection or from a psychogenic cause. Examine other head and neck structures (e.g., lymph nodes) and the temporomandibular joints (1). Look for meningeal signs, if appropriate.
B. Musculoskeletal examination. Palpate for muscle tenderness or spasm in the neck and head. Tender trigger points may be found in fibromyalgia. Assess active and passive range of motion (ROM) of the neck and shoulders. ROM is not affected with referred sources of pain. Decreased passive ROM may be seen in rheumatoid arthritis (RA), ankylosing spondylitis (AS), disseminated idiopathic skeletal hyperostosis (DISH), compression fractures, and cervical spondylosis. Active contraction or stretching of strained muscles or ligaments will precipitate pain.
C. Neurologic examination. Include the examination of cranial nerves, motor function, tone, and reflexes of the upper and lower extremities. Look for muscle atrophy. Check pinprick and light touch sensation in the upper extremities, looking for a dermatomal pattern of loss. Evaluate cerebellar, vibration, and position sense in the legs. The exact level of nerve root involvement cannot be precisely known from the physical examination because of overlapping innervation (2) (Table 12.9). A Spurling’s test (extension and rotation of the head and neck while applying downward pressure to the top of the head) that precipitates radicular symptoms is very suggestive of nerve root pathology (1).
Testing
A. Clinical laboratory testing. A complete blood count and erythrocyte sedimentation rate are warranted for suspected infection or neoplasm. A positive rheumatoid factor (RF) is found in more than two-thirds of patients with RA, but is also found in 10% to 20% of all elderly individuals. RF and antinuclear antibody are absent in AS. Creatine phosphokinase is elevated in myositis and, possibly, muscle trauma (Chapters 16.3 and 17.3).
B. Diagnostic radiology. Cervical spine films are mandatory after any spine trauma (3). A cross-table lateral film is used to rule out an unstable fracture or dislocation (2). The lateral view must include all seven cervical vertebrae as well as the C7-T1 interspace (3). Cervical spine films are also useful for a vertebral compression fracture, cancer, and rheumatologic disorders. Cortical erosion of the vertebral body indicates an inflammatory process. Increased width of the prevertebral soft tissues can suggest a prevertebral hematoma. Degenerative changes in the vertebral joints, also called spondylosis, are very common with aging and do not correlate well with symptomatology (1,2). Computed tomography scans are excellent for definitive delineation of bony fracture anatomy, when necessary. Magnetic resonance imaging (MRI) is the most effective means to evaluate the soft tissues of the neck. An MRI will distinguish between neoplasm and degenerative disorders of the vertebrae, and visualize ligamentous injury, occult disc herniation, hematoma, or edema around the spinal cord. MRI may identify abnormalities that have no clinical significance (1).
C. Other. An electromyogram (EMG) can delineate the site of a particular nerve lesion or clarify the diagnosis when symptoms and physical examination are discordant (1). An EMG may be negative in nerve damage of less than 3 weeks’duration (1,2).
Diagnostic assessment
A. Spondylosis. Degenerative changes can encroach on the spinal canal or intervertebral foramina. Consider spondylosis-related symptoms in patients aged more than 40 years. Symptoms affect men twice as often as women. Common symptoms include a unilateral or bilateral occipital headache that is worse in the morning and radiates to the frontal region, upper chest, and shoulders.
B. Radiculopathy or myelopathy. Radicular pain usually involves the proximal arm with more distal paresthesias (Table 12.9) (Chapter 4.6). Cervical myelopathy presents with upper extremity nerve root symptoms and long tract signs in the legs. Spasticity may be the most prominent neurologic change. Long tract signs in the legs occur uncommonly without root signs (2). Symptoms can be precipitated by neck movement. Myelopathy is more typically secondary to spondylosis rather than disc herniation.
C. Rheumatologic. Axial involvement with RA may be limited to the upper cervical spine; atlantoaxial subluxation can present as occipital pain. Subluxation can cause cord compression. DISH has a characteristic appearance on x-ray film. It is the most common rheumatologic process affecting the cervical spine, but rarely causes symptoms (1). AS also affects the cervical spine. Gout and pseudogout usually do not.
References
1. Swezey RI. Chronic neck pain. Rheum Dis Clin North Am 1996;22:411–437.
2. Cailliet R. Neck and arm pain. Philadelphia: FA Davis, 1989.
3. Graber MA, Kathol M. Cervical spine radiographs in the trauma patient. Am Fam Physician 1999;59:331–342.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Neck swelling
» Next page: Neck Pain (Field Guide to Bedside Diagnosis)
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