1. Neck Pain Nachii Narasinghan

2. Introduction F>M Highest prevalence in middle age Types –Non-specific –Whiplash –Cervical spondylosis –Acute torticollis

3. Assessing neck pain Exclude non-MSK causes Assess for red flags Assess range of neck movements Perform a neuro exam Identify risk factors for developing neck pain Identify psychosocial factors that may suggest increased risk for chronicity and disability

4. The negative predictive value of these ‘red flags’ clinical findings is high; –if no ‘red flags’ are present, then it is unlikely that a serious spinal abnormality has been missed. Individual positive findings must be interpreted with care, as their positive predictive value for diagnosing serious disease is poor (Williams and Hoving, 2004)

5. Red Flags 'Red flags' that suggest cancer, infection, or inflammation: –Malaise, fever, unexplained weight loss. –Pain that is increasing, is unremitting, or disturbs sleep. –History of inflammatory arthritis, cancer, tuberculosis, immunosuppression, drug abuse, AIDS, or other infection. –Lymphadenopathy. –Exquisite localized tenderness over a vertebral body. 'Red flags' that suggest severe trauma or skeletal injury: –A history of violent trauma (e.g. a road traffic accident) or a fall from a height. However, minor trauma may fracture the spine in people with osteoporosis. –A history of neck surgery. –Risk factors for osteoporosis: premature menopause, use of systemic steroids.

6. 'Red flags' that suggest vascular insufficiency: –Dizziness and blackouts (restriction of vertebral artery) on movement, especially extension of the neck when gazing upwards. –Drop attacks. 'Red flags' that suggest compression of the spinal cord (myelopathy): –Insidious progression. –Neurological symptoms gait disturbance, clumsy or weak hands, or loss of sexual, bladder, or bowel function. –Neurological signs: Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs. UMN signs in the lower limbs (Babinski's sign — up-going plantar reflex, hyperreflexia, clonus, spasticity). LMN signs in the upper limbs (atrophy, hyporeflexia). Sensory changes are variable, with loss of vibration and joint position sense more evident in the hands than in the feet.

7. Investigations Cervical x-rays and other imaging are not routinely required in the dx or assessment of neck pain with radiculopathy or non- specific neck pain. Best to be open about limitations of investigations and reassure patients that they can be helped without such investigations.

8. What should be done with patients with neck pain? (x-ray shows cervical spondylosis) Degenerative changes affecting C-spine discs and facet joints Depends on clinical picture

9. Abnormal neurology, or persistent or progressive brachialgia with or without abnormal neurology, warrants neurosurgical investigation Surgery is good at reducing compressive nerve root symptoms and signs and arresting myelopathic progression. Surgery is less good at reducing myelopathic symptoms and signs when these are chronic Urgency of referral depends on the severity of neurological deficit and rate of progression.

10. Basis for recommendation In the absence of ‘red flags’ plain X-rays of the cervical spine are unlikely to help and may lead to false-positive findings (Williams and Hoving). Features of degenerative disease are also common in asymptomatic people older than 30 years of age and correlate poorly with clinical symptoms. (Binder,2007).

11. Neck pain Acute (3-4 weeks) Sub-acute (4-12 weeks) Chronic

12. Acute neck pain Encourage the patient to: –remain as active as possible –restore their neck movements as pain allows –correct poor posture if precipitating or aggravating the neck pain –sleep with one pillow which provides lateral –support and also gives support to the hollow of the neck. Two pillows may force the head into an unnatural position.

13. Discourage the patient from: –prolonged absence from work –wearing a cervical collar (which may hinder recovery).

14. Sub acute neck pain Refer to physiotherapy for a multimodal treatment –strategy that includes postural advice, exercises and manual therapy. Acupuncture may be included at this stage. Promote positive attitudes to activity and work. Address any psychosocial factors Consider referral to a psychologist or occupational health clinician.

15. Chronic neck pain Continue physiotherapy if it is helping, discontinue if not. Avoid passive interventions, e.g. electrotherapy and massage. Reassess psychological factors. Consider referral to a pain clinic for people with chronic pain or nerve root symptoms where there is poor control.

17. Take home messages Be aware of red flags in the assessment of neck pain. Mainstay of the initial management of simple neck pain is conservative and in primary care. Role of imaging is limited.

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