Approach to neck pain

APPROACH TO NECK PAINAPPROACH TO NECK PAIN

Dr. Yassir Hussain.PDr. Yassir Hussain.P

In GeneralIn General

Difficult to arrive at an anatomical Difficult to arrive at an anatomical diagnosisdiagnosis

Most important is to be able to Most important is to be able to recognize a serious pain staterecognize a serious pain state

Differentiate neck pain due to Differentiate neck pain due to common diseases from neck pain common diseases from neck pain due to local pathologydue to local pathology

EPIDEMIOLOGYEPIDEMIOLOGY Very common; 2 out of 3 people Very common; 2 out of 3 people

experience neck pain at some point in experience neck pain at some point in lifelife

High among the working aged High among the working aged populacepopulace

Incidence in general populace is 10-Incidence in general populace is 10-20%20%

25-40% complain of associated 25-40% complain of associated radiation to upper extremityradiation to upper extremity

Epidemiology..Epidemiology..

In the population>45 yrs old >50% In the population>45 yrs old >50% have neck pain/stiffnesshave neck pain/stiffness

Incidence is higher in women & 30-Incidence is higher in women & 30-50 year old adults50 year old adults

Whiplash injuries are a common Whiplash injuries are a common causecause

RTA & WhiplashRTA & Whiplash

62% of RTA victims have whiplash62% of RTA victims have whiplash 33-66% develop symptoms within 24 33-66% develop symptoms within 24

hourshours 30-42% have continued intermittent 30-42% have continued intermittent

pain at 1 yearpain at 1 year 6% have continuous pain at 1 year6% have continuous pain at 1 year 28% have chronic pain28% have chronic pain

CLASSIFICATIONCLASSIFICATION

LocalLocal Acute- <12 weeksAcute- <12 weeks Chronic- >12 weeksChronic- >12 weeks

RadiatingRadiating WhiplashWhiplash

Alternative classificationAlternative classification

Arising from the muscles, ligaments Arising from the muscles, ligaments & joints of the neck& joints of the neck

Arising from the cervical nerve roots Arising from the cervical nerve roots or the spinal cordor the spinal cord

PAIN SENSITIVE PAIN SENSITIVE STRUCTURESSTRUCTURES

ExaminationExamination

HistoryHistory Onset-Acute or Insidious?Onset-Acute or Insidious? Site of painSite of pain CharacterCharacter RadiationRadiation Radiation- Dermatomal or diffuse?Radiation- Dermatomal or diffuse? Aggravating factors and relieving factorsAggravating factors and relieving factors Prior traumaPrior trauma

History..History..

Joint pain?Joint pain? Prior general diseases?Prior general diseases? General symptoms- fever ,weight loss General symptoms- fever ,weight loss

etc.etc. Symptoms of neurological Symptoms of neurological

complications- weakness, parasthesiae, complications- weakness, parasthesiae, gait disorders, vertigo, visual gait disorders, vertigo, visual disturbances disturbances

Examination..Examination..

InspectionInspection Supraclavicular fossae- asymmetry?Supraclavicular fossae- asymmetry? sternocliedomastoid-spasm/swellingsternocliedomastoid-spasm/swelling

PalpationPalpation Midline tenderness posteriorly- Midline tenderness posteriorly-

spondylosis/infectionsspondylosis/infections Paraspinal tenderness- swellings/muscle Paraspinal tenderness- swellings/muscle

spasmspasm


Anterior neck-supraclavicular fossae-Anterior neck-supraclavicular fossae-swellings/cervical ribsswellings/cervical ribs

Thyriod?/ salivary glands?Thyriod?/ salivary glands? LNE?LNE? Temporal artery tenderness/induration?Temporal artery tenderness/induration?


MovementsMovements FlexionFlexion ExtensionExtension Lateral flexionLateral flexion RotationRotation

Check for active and passive motionCheck for active and passive motion The shoulders should be horizontal The shoulders should be horizontal

while testing for movementswhile testing for movements Normally the chin can touch the chestNormally the chin can touch the chest

Examination..Examination.. If lateral flexion cannot be carried out If lateral flexion cannot be carried out

without forward flexion this shows without forward flexion this shows involvement of the first two jointsinvolvement of the first two joints

When checking for rotation the When checking for rotation the shoulder should be restrained by the shoulder should be restrained by the physicianphysician

1/3 rd of rotation occurs at the first two 1/3 rd of rotation occurs at the first two jointsjoints

The nose & forehead should be in the The nose & forehead should be in the horizontal plane on full extensionhorizontal plane on full extension

1/5 th of flexion-extension & lateral 1/5 th of flexion-extension & lateral rotation occur at the first two joints.rotation occur at the first two joints.


When checking for passive motion place When checking for passive motion place the patient erect on a stool. standing the patient erect on a stool. standing behind the patient the left hand behind the patient the left hand stabilizes the shoulder blades in the stabilizes the shoulder blades in the horizontal plane while the left test for horizontal plane while the left test for extension and rotation starting from the extension and rotation starting from the neutral.neutral.

When testing for flexion the hands are When testing for flexion the hands are reversed.reversed.

Normal range of motionNormal range of motion

Flexion :80°Flexion :80° Extension :50°Extension :50° Lateral flexion :45°Lateral flexion :45° Rotation :80° to either sideRotation :80° to either side

Examination..Examination.. If there is pain try to differentiate If there is pain try to differentiate

whether pain arises from the neck or whether pain arises from the neck or shoulder or both.shoulder or both.

Reflex muscle spasm due to pain will Reflex muscle spasm due to pain will cause limitation of movements but cause limitation of movements but this can be overcome passivelythis can be overcome passively

If real limitation of movements If real limitation of movements persists it indicates structural damage persists it indicates structural damage within the corresponding joints. within the corresponding joints.


Mechanical problems usually cause Mechanical problems usually cause asymmetric limitation of movementasymmetric limitation of movement

Inflammatory/ Neoplastic disorders Inflammatory/ Neoplastic disorders on the other hand are widespread on the other hand are widespread and more or less symmetric ; hence and more or less symmetric ; hence pain & movement restriction will also pain & movement restriction will also be symmetricbe symmetric

Movements..Movements..

Movements..Movements..

PASSIVE MOTION PASSIVE MOTION EXAMINATIONEXAMINATION


Specific testsSpecific tests C1-C7 neurological exam & further as C1-C7 neurological exam & further as

req.req. CrepitusCrepitus Cervical ribCervical rib RadiculopathyRadiculopathy MyelopathyMyelopathy

Neurological examNeurological exam C1-C4 involvement will show no motor C1-C4 involvement will show no motor

weakness or reflex changes clinicallyweakness or reflex changes clinically

C5 C6 C7 C8 Sensory Lateral arm Thumb Middle finger Little finger Motor Deltoid Wrst extensors Tricep Finger flexion Disc C4-C5 C5-C6 C6-C7 C7-T1 Reflex Bicep Brachioradialis Tricep


It is possible to test the sensory It is possible to test the sensory supply of C2-C4supply of C2-C4

Neck flexion/lateral flexion are by Neck flexion/lateral flexion are by C2,C3 & spinal accessoryC2,C3 & spinal accessory

Neck extension is by C3,C4,spinal Neck extension is by C3,C4,spinal accessory & the posterior rami of accessory & the posterior rami of spinal nrvesspinal nrves

Trapezius reflex is mediated by Trapezius reflex is mediated by C3,C4C3,C4

Specific..Specific..

CrepitusCrepitus Spread both hands on either side of the Spread both hands on either side of the

neck and ask patient to flex and extend neck and ask patient to flex and extend the neck.the neck.

Facet joint crepitus-a common finding in Facet joint crepitus-a common finding in spondylosis is feltspondylosis is felt

If in doubt auscultateIf in doubt auscultate

CrepitusCrepitus


Cervical ribCervical rib Look for vascular deficits in the upper limbLook for vascular deficits in the upper limb Adsons test-patient takes a deep breath Adsons test-patient takes a deep breath

and turns his head toward the side of the and turns his head toward the side of the lesion; watch for radial pulse obliteration lesion; watch for radial pulse obliteration or decreaseor decrease

Auscultate over supraclavicular area to Auscultate over supraclavicular area to check for murmur of subclavian artery check for murmur of subclavian artery compression compression


RadiculopathyRadiculopathy Lateral stretch testLateral stretch test Cervical compression test/anvil Cervical compression test/anvil

test/Spurlings testtest/Spurlings test Distraction testDistraction test Shoulder abduction relief testShoulder abduction relief test Tinels signTinels sign Upper limb tension testsUpper limb tension tests

Radiculopathy..Radiculopathy.. Lateral stretch testLateral stretch test

Stretching of the neck in the opposite Stretching of the neck in the opposite direction will elicit pain along the direction will elicit pain along the nerve root distributionnerve root distribution

Contd..Contd.. Spurlings testSpurlings test

Sit the patient on a stool with head Sit the patient on a stool with head in neutral position & with the head in neutral position & with the head in 45 degree rotation to either side in 45 degree rotation to either side with the head tilted toward the with the head tilted toward the ceiling.ceiling.

In each of these three positions In each of these three positions apply brisk compression in the line apply brisk compression in the line of the spine standing behind the of the spine standing behind the patient.patient.

If the patient suffers from If the patient suffers from foraminal stenosis of any cause foraminal stenosis of any cause there will be root pain along the there will be root pain along the distribution of the concerned rootdistribution of the concerned root

Spurlings testSpurlings test

Radiculopathy..Radiculopathy..

Distraction testDistraction test Passively elevating the head in Passively elevating the head in the neutral position by holding it the neutral position by holding it at the occiput and chin will at the occiput and chin will relieve symptomsrelieve symptoms

Anvil & Distraction testAnvil & Distraction test


Shoulder abduction relief testShoulder abduction relief test Significant relief of pain with Significant relief of pain with shoulder abductionshoulder abduction

Seen in soft cervical disk prolapseSeen in soft cervical disk prolapse Negative in radiculopathy due to Negative in radiculopathy due to spondylosisspondylosis


Tinels signTinels sign In radiculopathy direct palpation In radiculopathy direct palpation or percussion over the exiting or percussion over the exiting nerve root may provoke the nerve root may provoke the patients typical painpatients typical pain

If it is found to be positive more If it is found to be positive more laterally ,such as over the laterally ,such as over the supraclavicular fossae then the supraclavicular fossae then the diagnosis should be questioneddiagnosis should be questioned

Upper limb tension test 1Upper limb tension test 1

ULTT1ULTT1

ULTT1ULTT1


ULTT2ULTT2

ULTT2ULTT2




Radiculopathy may be associated with Radiculopathy may be associated with myelopathymyelopathy

Can involve one or multiple rootsCan involve one or multiple roots Findings may overlap due to intraneural Findings may overlap due to intraneural

intersegmental connections of sensory intersegmental connections of sensory nerve rootsnerve roots

Radiculopathy..Radiculopathy.. Neurological findings suggestive of Neurological findings suggestive of

radiculopathy besides the above signs radiculopathy besides the above signs areare

Pain/ parasthesiae aggravated by Pain/ parasthesiae aggravated by coughing/sneezingcoughing/sneezing

Parasthesiae along nerve root Parasthesiae along nerve root distributiondistribution

Pain & tenderness along muscles of the Pain & tenderness along muscles of the involved myotomeinvolved myotome

Weakness of said musclesWeakness of said muscles Depressed reflexes corresponding to the Depressed reflexes corresponding to the

involved rootinvolved root Basically LMN signs.Basically LMN signs.


MyelopathyMyelopathy LMN signs in the upper limbs at the LMN signs in the upper limbs at the level of compression (flaccid level of compression (flaccid paralysis, muscle atrophy, absent paralysis, muscle atrophy, absent reflexes)reflexes)

UMN signs below the level of the UMN signs below the level of the lesion, mainly evident in the lower lesion, mainly evident in the lower limbs. (hypertonicity, hyperreflexia, limbs. (hypertonicity, hyperreflexia, clonus, Babinskis sign)clonus, Babinskis sign)

Sensory deficit is non dermatomal Sensory deficit is non dermatomal involving large areas e.g.-whole involving large areas e.g.-whole arm/forearm/wristarm/forearm/wrist

Bladder involvement may be presentBladder involvement may be present Funicular pain (burning pain)Funicular pain (burning pain)

Other signs of myelopathyOther signs of myelopathy Hoffman's test/dynamic Hoffman's test/dynamic Hoffmann's testHoffmann's test

Lhermittes signLhermittes sign Inverted supinator jerk/inverted Inverted supinator jerk/inverted radial reflexradial reflex

ClonusClonus Myelopathy handMyelopathy hand Gait abnormalities such as ataxic Gait abnormalities such as ataxic broad based shuffling gaitbroad based shuffling gait

Myelopathy..Myelopathy..

Hoffmann's testHoffmann's test Rapidly extend the distal phalanx of the Rapidly extend the distal phalanx of the

middle finger by flicking its pulpmiddle finger by flicking its pulp Positive if there is flexing of the IP joints Positive if there is flexing of the IP joints

of the index & thumbof the index & thumb Dynamic Hoffmann's testDynamic Hoffmann's test

Repeat while the patient flexes & extends Repeat while the patient flexes & extends the neck which facilitates the responsethe neck which facilitates the response


Lhermittes testLhermittes test Flexion or extension produces electric Flexion or extension produces electric

shock like sensations , particularly in the shock like sensations , particularly in the legs.legs.

Inverted supinator jerkInverted supinator jerk While eliciting the brachioradialis jerk While eliciting the brachioradialis jerk

instead of brachioradialis contraction we instead of brachioradialis contraction we get flexion of the fingers of the handget flexion of the fingers of the hand

Highly specific for lesion at C5Highly specific for lesion at C5

Myelopathy..Myelopathy.. Myelopathy handMyelopathy hand

KineticKinetic Inability to flex & extend the fingers Inability to flex & extend the fingers

rapidlyrapidly Time over 10 secondsTime over 10 seconds Usually in excess of 20 cyclesUsually in excess of 20 cycles

PosturalPostural Deficient adduction & often extension Deficient adduction & often extension

of the ulnar 1-3 fingersof the ulnar 1-3 fingers

Myelopathy..Myelopathy.. In the mildest cases when the fingers In the mildest cases when the fingers

are extended the little finger lies are extended the little finger lies slightly in abduction; even if slightly in abduction; even if adduction is possible it cannot be held adduction is possible it cannot be held for long. abduction is normal (finger for long. abduction is normal (finger escape sign)escape sign)

If severe the little, ring & sometimes If severe the little, ring & sometimes the middle finger may abduct and/or the middle finger may abduct and/or the same fingers may flex & loose the same fingers may flex & loose their power of extensiontheir power of extension..

Myelopathy is most common at C5 ,first Myelopathy is most common at C5 ,first affecting deltoid & infraspinatusaffecting deltoid & infraspinatus


Motor weakness when present is Motor weakness when present is asymmetric & usually affects asymmetric & usually affects multiple levelsmultiple levels

Vibration & position sense are often Vibration & position sense are often reducedreduced

Babinskis sign becomes positive only Babinskis sign becomes positive only late in the diseaselate in the disease


Any lesion which compresses the Any lesion which compresses the cord can cause myelopathy but in cord can cause myelopathy but in particular considerparticular consider Canal stenosisCanal stenosis SpondylosisSpondylosis Cervical kyphosisCervical kyphosis Old dens # non unionOld dens # non union

Investigated best by CT Investigated best by CT myelography, MRI or dynamic MRImyelography, MRI or dynamic MRI

Anatomy of compressionAnatomy of compression

Anterior Anterior compression-IVDP/osteophytescompression-IVDP/osteophytes

Anterolateral compression-joints of Anterolateral compression-joints of LuschkaLuschka

Lateral compression- facet jointsLateral compression- facet joints Posterior compression- ligamentum Posterior compression- ligamentum

flavumflavum

How to differentiate the source How to differentiate the source of neck painof neck pain

Pain from joints Pain from joints ligaments/musclesligaments/muscles

c/o pain & stiffnessc/o pain & stiffness Deep, dull aching & Deep, dull aching &

often episodic painoften episodic pain h/o h/o

excessive/unaccustoexcessive/unaccustomed activity or of med activity or of sustaining an sustaining an awkward postureawkward posture

Pain from nerve Pain from nerve roots or the roots or the spinal cordspinal cord

c/o root painc/o root pain Sharp, intense Sharp, intense

often burning painoften burning pain Radiates to Radiates to

trapezial, trapezial, interscapular areas interscapular areas or down the armor down the arm

Differentiation Contd..Differentiation Contd..

No h/o injuryNo h/o injury Localized Localized

asymmetric painasymmetric pain Upper cervical pain Upper cervical pain

is referred to the is referred to the head, lower head, lower cervical to the armcervical to the arm

Aggravated by Aggravated by movement, movement, relieved by restrelieved by rest

Numbness & motor Numbness & motor weakness in a weakness in a myotomal myotomal distributiondistribution

Headache may occur Headache may occur with upper root with upper root involvementinvolvement

Symptoms Symptoms aggravated by neck aggravated by neck hyperextension.hyperextension.

When to suspect serious When to suspect serious diseasedisease

Unrelenting symptoms and pain Unrelenting symptoms and pain radiating to both handsradiating to both hands

Systemic causes such asSystemic causes such as Ankylosing spondylitisAnkylosing spondylitis PolymyalgiaPolymyalgia Malignancy/myeloma/metastasisMalignancy/myeloma/metastasis Osteomyelitis/tuberculosisOsteomyelitis/tuberculosis

MyelopathyMyelopathy Progressively increasing pain c.f Progressively increasing pain c.f

episodicepisodic

Is the patient faking?Is the patient faking?

Non-organic signs of WaddellNon-organic signs of Waddell Nonanatomic tendernessNonanatomic tenderness Simulation signSimulation sign Distraction signDistraction sign Regional motor or sensory disturbanceRegional motor or sensory disturbance OverreactionOverreaction

Waddell's signsWaddell's signs

Their interpretation depends on the Their interpretation depends on the experience of the physician with a experience of the physician with a wide range of patientswide range of patients

The signs are significant when more The signs are significant when more than one are present in the same than one are present in the same patientpatient

The most sensitive sign is The most sensitive sign is overreactionoverreaction

Nonanatomic tendernessNonanatomic tenderness

Said to be present when the patient Said to be present when the patient complains of pain with extremely light complains of pain with extremely light touch or tenderness whose distribution touch or tenderness whose distribution does not conform to the distribution of does not conform to the distribution of known anatomic structuresknown anatomic structures

Verified by palpating areas that are Verified by palpating areas that are not usually tendernot usually tender

CRPS is an exceptionCRPS is an exception

Simulation signSimulation sign

Positive under two circumstancesPositive under two circumstances Patient c/o pain along the whole Patient c/o pain along the whole

length of spine or in the lower back length of spine or in the lower back in response to spurlings testin response to spurlings test

Patient c/o pain when the rotation Patient c/o pain when the rotation simulation maneuver is done i.e head simulation maneuver is done i.e head & shoulders are rotated in a manner & shoulders are rotated in a manner coplanar with the pelviscoplanar with the pelvis

Distraction signDistraction sign

Pertinent only in case of back painPertinent only in case of back pain Patient c/o pain in the SLR test but Patient c/o pain in the SLR test but

fails to do so when the knee is fails to do so when the knee is extended from the seated positionextended from the seated position

Regional motor/sensory Regional motor/sensory disturbancedisturbance

Regional sensory disturbance exists Regional sensory disturbance exists when there is sensory disturbance in when there is sensory disturbance in a nonanatomic distribution such as a nonanatomic distribution such as glove & stocking distributionglove & stocking distribution

Regional motor disturbance is Regional motor disturbance is suspected if there is diffuse weakness suspected if there is diffuse weakness in multiple muscle groups/in the in multiple muscle groups/in the whole limb etc or if the examiner whole limb etc or if the examiner feels that the patients muscles give feels that the patients muscles give way in an unphysiological manner way in an unphysiological manner during strength testingduring strength testing

OverreactionOverreaction

Present when the patient reacts Present when the patient reacts physically or verbally in an physically or verbally in an inappropriately theatrical manner in inappropriately theatrical manner in response to light palpation or gentle response to light palpation or gentle methods of examinationmethods of examination

INVESTIGATIONSINVESTIGATIONS Plain x rays Plain x rays Stress x raysStress x rays CTCT MRIMRI MyelographyMyelography Nerve conduction Nerve conduction

studies/electromyographystudies/electromyography Nerve blocksNerve blocks DiscographyDiscography

Investigations..Investigations..

As requiredAs required ECGECG Blood R/EBlood R/E LFTLFT S.electrophoresisS.electrophoresis


X rays AP, lateral, obliqueX rays AP, lateral, oblique More useful when acute severe injury is More useful when acute severe injury is

suspectedsuspected Tumors, infections are other instancesTumors, infections are other instances Oblique view shows foraminaOblique view shows foramina

Stress x raysStress x rays Used to demonstrate spinal instability in Used to demonstrate spinal instability in

patients without neurological deficits patients without neurological deficits whose plain films show no findingswhose plain films show no findings


CTCT Detects # missed by x raysDetects # missed by x rays Useful in assessing spinal canal/foraminaUseful in assessing spinal canal/foramina

MRIMRI Helps in diagnosing disc rupture/herniationHelps in diagnosing disc rupture/herniation Intraspinal soft tissue processes Intraspinal soft tissue processes

e.g.-intra/epidural abscesses, hematomas, e.g.-intra/epidural abscesses, hematomas, Intraspinal tumorsIntraspinal tumors


Degenerative disc changes present in Degenerative disc changes present in 25% of asymptomatic adults under 40 25% of asymptomatic adults under 40 yrs,60% of those over 40 years & 70% of yrs,60% of those over 40 years & 70% of those over 70 yrsthose over 70 yrs


Myelography/contrast CTMyelography/contrast CT To study the relation between bony & To study the relation between bony &

neural structures for pre-op planningneural structures for pre-op planning Nerve blocksNerve blocks

Facet block/cervical sympathetic Facet block/cervical sympathetic blocks/trigger point blocks etc help to blocks/trigger point blocks etc help to diagnose the site of lesion as well as diagnose the site of lesion as well as being therapeutic occasionallybeing therapeutic occasionally


DiscographyDiscography May help in identifying the affected discMay help in identifying the affected disc May identify disc rupture missed by MRIMay identify disc rupture missed by MRI However the risks generally outweigh the However the risks generally outweigh the

benefitsbenefits.. Nerve conduction Nerve conduction

studies/electromyographystudies/electromyography Help confirm radiculopathyHelp confirm radiculopathy Only way to diagnose C3,C4 radiculopathy Only way to diagnose C3,C4 radiculopathy

is EMGis EMG

Differential diagnosisDifferential diagnosis

““Tension neck”Tension neck” TorticollisTorticollis FibromyalgiaFibromyalgia Myofascial pain syndromesMyofascial pain syndromes Cervical spondylosisCervical spondylosis Cervical IVDPCervical IVDP Whiplash (#, dislocations, ligamental Whiplash (#, dislocations, ligamental

injuries)injuries)

DdDdContd..Contd..

Infections-TB, Osteomyelitis, epidural Infections-TB, Osteomyelitis, epidural abscessabscess

Tumors-primary & metastaticTumors-primary & metastatic MyelopathyMyelopathy Cervical stenosisCervical stenosis OA of facet joints/joints of LuschkaOA of facet joints/joints of Luschka Brachial plexus pathologiesBrachial plexus pathologies

DdDdContd..Contd..

Thoracic outlet syndromeThoracic outlet syndrome CRPSCRPS Herpes ZosterHerpes Zoster Inflammatory pathology e.g.-Inflammatory pathology e.g.-

Rheumatoid arthritis, Ankylosing Rheumatoid arthritis, Ankylosing spondylitisspondylitis

SyringomyeliaSyringomyelia Transverse myelitisTransverse myelitis

DdDdContd..Contd..

MeningismMeningism Severe arterial hypertension Severe arterial hypertension

(suboccipital pain)(suboccipital pain) Epidural heamorrhageEpidural heamorrhage CVJ/vertebral anomaliesCVJ/vertebral anomalies MyopathiesMyopathies Pain from shoulder joint/rotator cuffPain from shoulder joint/rotator cuff

DdDdContd..Contd..

Pain from the upper limb e.g.-lat. Pain from the upper limb e.g.-lat. Epicondylitis, CTSEpicondylitis, CTS

angina pectoris/MI- if risk angina pectoris/MI- if risk factors/associated with exertion, factors/associated with exertion, ”cervical angina syndrome””cervical angina syndrome”

Abdominal irritation e.g.-Abdominal irritation e.g.-cholecystopathic paincholecystopathic pain

Nonspecific neck and shoulder Nonspecific neck and shoulder painpain

TorticollisTorticollis ““Tension neck”Tension neck” FibromyalgiaFibromyalgia Myofascial pain syndromesMyofascial pain syndromes

Torticollis (Wry neck)Torticollis (Wry neck) Rotational deformity of upper Rotational deformity of upper

cervical spine causing turning & cervical spine causing turning & tilting of the headtilting of the head

Head tilted to involved side & chin to Head tilted to involved side & chin to opposite sideopposite side

Due to wide number of causesDue to wide number of causes CongenitalCongenital NeurologicNeurologic InflammatoryInflammatory TraumaticTraumatic

Torticollis..Torticollis..

Congenital may be due muscular wry Congenital may be due muscular wry neck or due to anomalies of upper neck or due to anomalies of upper cervical spine like klippel-feil syndrome, cervical spine like klippel-feil syndrome, basilar impression, odontoid anoimalies, basilar impression, odontoid anoimalies, Atlanto-occipital fusion etcAtlanto-occipital fusion etc

Neurologic abnormalities like ocular Neurologic abnormalities like ocular dysfunction, dysfunction, syrigomyelia,s.cord/cerebellar tumors can syrigomyelia,s.cord/cerebellar tumors can lead to torticollislead to torticollis

Torticollis..Torticollis..

Inflammation can cause torticollis Inflammation can cause torticollis such as cervical lymphadenitis, such as cervical lymphadenitis, rotatory subluxation of childhoodrotatory subluxation of childhood

Trauma of any sort to upper spine Trauma of any sort to upper spine especially C1-C2 is another causeespecially C1-C2 is another cause

Tension neckTension neck Patient c/o neck pain usually in the Patient c/o neck pain usually in the

suboccipital & posterior aspectssuboccipital & posterior aspects Muscle tenderness will be presentMuscle tenderness will be present H/o stress/holding head in abnormal H/o stress/holding head in abnormal

position/unaccustomed work/faulty position/unaccustomed work/faulty posture will be presentposture will be present

Pain may radiate to scalp due to Pain may radiate to scalp due to irritation of superior occipital nerveirritation of superior occipital nerve

FibromyalgiaFibromyalgia

Clinical syndrome charachterized by Clinical syndrome charachterized by diffuse vague pain, extreme fatigue, diffuse vague pain, extreme fatigue, stiffness, tender points, sleep stiffness, tender points, sleep disturbancedisturbance

Thought to be due to disturbance in Thought to be due to disturbance in stage 4 NREM sleepstage 4 NREM sleep

Diagnosed by Diagnosed by h/o widespread pain especially h/o widespread pain especially

shoulder/pelvic girdleshoulder/pelvic girdle Pain at 11 out of 18 tender points on 4 kg Pain at 11 out of 18 tender points on 4 kg

forceforce

Fibromyalgia tender pointsFibromyalgia tender points

Fibromyalgia Contd..Fibromyalgia Contd..

Pain in muscles & jointsPain in muscles & joints Worst in the morningWorst in the morning muscle tone, breakaway weakness, muscle tone, breakaway weakness,

livedo reticularis may be presentlivedo reticularis may be present Joints are not tender.Joints are not tender. Skin fold roll test-rolling of skin fold Skin fold roll test-rolling of skin fold

at T12 level from below upwards will at T12 level from below upwards will cause severe paincause severe pain

Myofascial pain syndromeMyofascial pain syndrome Diagnosis is made when on Diagnosis is made when on

examination we find trigger points in examination we find trigger points in the affected musclesthe affected muscles

Trigger points are tender knotted Trigger points are tender knotted points that on palpation will cause points that on palpation will cause pain at a different sitepain at a different site

Infiltration with lignocaine is useful Infiltration with lignocaine is useful both as a diagnostic & therapeutic both as a diagnostic & therapeutic testtest

Cervical SpondylosisCervical Spondylosis Actually is a combination of Actually is a combination of

degenerative & herniated IVDPdegenerative & herniated IVDP Also called osteoarthritis, Also called osteoarthritis,

osteoarthrosis, chronic herniated disk, osteoarthrosis, chronic herniated disk, chondroma, spur formation, chondroma, spur formation, osteophytosisosteophytosis

Seen in 75% of those .65yrs oldSeen in 75% of those .65yrs old May present as neck pain & May present as neck pain &

myelopathy ,Neck pain & radiculopathy myelopathy ,Neck pain & radiculopathy or progressive myelopathyor progressive myelopathy

Spondylosis..Spondylosis..

Radiculopathy due to osteophytesRadiculopathy due to osteophytes Myelopathy due to stenosis, Myelopathy due to stenosis,

osteophytes & PLL calcificationosteophytes & PLL calcification Most commonly affects C5-C6,C6-C7 & Most commonly affects C5-C6,C6-C7 &

C4-C5C4-C5 Occiput to C3 involvement is Occiput to C3 involvement is

uncommonuncommon Vertebral artery maybe involved in the Vertebral artery maybe involved in the

transverse foramentransverse foramen


Arthritis of facet joints or joints of Arthritis of facet joints or joints of Luschka can cause painLuschka can cause pain

Disk degeneration leads to IVDPDisk degeneration leads to IVDP Cervical Spondylosis without pain is Cervical Spondylosis without pain is

similar to Multiple sclerosis similar to Multiple sclerosis (involvement above f.magnum), (involvement above f.magnum), Amyotrophic lateral sclerosis (no Amyotrophic lateral sclerosis (no sensory changes, mixed UMN & LMN sensory changes, mixed UMN & LMN of all limbs), Syringomyelia and spinal of all limbs), Syringomyelia and spinal cord tumorcord tumor


When there is cervical IVDP pain is a When there is cervical IVDP pain is a poor guide to localization, poor guide to localization, sensory/motor loss & reflex changes sensory/motor loss & reflex changes are a better guideare a better guide

1/41/4thth have sensory loss have sensory loss 1/31/3rdrd have subjective weakness have subjective weakness 3/43/4thth have objective weakness have objective weakness

Cervical canal stenosisCervical canal stenosis Risk of spinal cord injury is greater if trauma Risk of spinal cord injury is greater if trauma

occursoccurs Torg ratioTorg ratio

Diameter of canal: width of cervical body Diameter of canal: width of cervical body (AP)(AP)

<0.8 indicates stenosis<0.8 indicates stenosis Pavlov ratioPavlov ratio

Canal: vertebral body widthCanal: vertebral body width Normally 1 ,<0.85 stenosis,<0.8 high risk for Normally 1 ,<0.85 stenosis,<0.8 high risk for

later injury-it also indicates congenital later injury-it also indicates congenital stenosisstenosis

Absolute stenosis-AP diameter<10mmAbsolute stenosis-AP diameter<10mm Relative stenosis-AP diameter10-13 mm Relative stenosis-AP diameter10-13 mm

(normal is 17)(normal is 17)

Spinal cord lesionsSpinal cord lesions

Produce deep, constant, progressive Produce deep, constant, progressive pain not pain not by coughing/sneezing by coughing/sneezing

Spinal epidural abscess starts as Spinal epidural abscess starts as localized ,boring pain which leads to localized ,boring pain which leads to muscle spasm & cervical rigidity muscle spasm & cervical rigidity rapidly progressing to cord rapidly progressing to cord progression. MRI is the investigation progression. MRI is the investigation of choiceof choice

Cord lesions..Cord lesions..

Spinal epidural hemorrhage presents Spinal epidural hemorrhage presents as sudden severe pain with radicular as sudden severe pain with radicular component and respiratory component and respiratory distress.50% have motor symptoms distress.50% have motor symptoms in 12 hours.15% are due to trauma. in 12 hours.15% are due to trauma. Investigated best by MRI/CTInvestigated best by MRI/CT

Herpes zosterHerpes zoster

Usually affects 1 root occasionally 2-3 Usually affects 1 root occasionally 2-3 rootsroots

Usually vesicles appear first then painUsually vesicles appear first then pain Severe lancinating painSevere lancinating pain Involves only one side of the bodyInvolves only one side of the body In C2 involvement the pain appears first In C2 involvement the pain appears first

as the vesicles are hidden by the as the vesicles are hidden by the hair/earhair/ear

Motor weakness in 60%Motor weakness in 60%

SyringomyeliaSyringomyelia Due to disturbed hydrodynamics of Due to disturbed hydrodynamics of

spinal fluid resulting in central syrinx spinal fluid resulting in central syrinx formationformation

More common in thoracic than cervical More common in thoracic than cervical area area

Maybe idiopathic, traumatic or Maybe idiopathic, traumatic or associated with spinal cord tumorassociated with spinal cord tumor

Idiopathic form associated with Arnold –Idiopathic form associated with Arnold –Chiari malformationsChiari malformations

Syringomyelia..Syringomyelia..

Occurs in 1-3 % of spine traumaOccurs in 1-3 % of spine trauma Presents as radicular pain, spasticity, Presents as radicular pain, spasticity,

dissociative anaesthesia in the form of dissociative anaesthesia in the form of “cape” sensory loss, LMN signs at the “cape” sensory loss, LMN signs at the level of the syrinx (usually the arms)level of the syrinx (usually the arms)

If ir enlarges then UMN LL sings developIf ir enlarges then UMN LL sings develop 25-80% have left thoracic scoliosis25-80% have left thoracic scoliosis MRI is investigation of choiceMRI is investigation of choice

Brachial plexus pathologyBrachial plexus pathology Two types of brachial plexus Two types of brachial plexus

pathology cause neck painpathology cause neck pain Preganglionic plexus injuriesPreganglionic plexus injuries Brachial neuritisBrachial neuritis

Preganglionic brachial plexus Preganglionic brachial plexus lesionslesions

Can cause severe pain along the Can cause severe pain along the neck ,shoulder & arm with an anaesthetic neck ,shoulder & arm with an anaesthetic limb when the upper plexus is involvedlimb when the upper plexus is involved

Look for features of C5, C6 involvement Look for features of C5, C6 involvement by examining myotomes and by examining myotomes and dermatomes.dermatomes.

C5 myotome is mainly deltoid, C5 myotome is mainly deltoid, dermatome is lower deltoiddermatome is lower deltoid

C6 myotome is tested by testing for C6 myotome is tested by testing for supination/ pronation, dermatome is supination/ pronation, dermatome is index fingerindex finger

Preganglionic..Preganglionic.. Reflexes affected are biceps & Reflexes affected are biceps &

brachioradialisbrachioradialis Preganglionic nature is diagnosed byPreganglionic nature is diagnosed by

Nerve to serratus anterior involvementNerve to serratus anterior involvement Dorsal scapular nerve involvement Dorsal scapular nerve involvement

(Levator scapulae & rhomboids)(Levator scapulae & rhomboids) Long tracts of spinal cord involvementLong tracts of spinal cord involvement Retention of sensory conduction in the Retention of sensory conduction in the

presence of sensory losspresence of sensory loss

Preganglionic..Preganglionic..

Histamine testHistamine test Anaesthesia above the clavicleAnaesthesia above the clavicle Elevated hemidaiphragm (in CXR)Elevated hemidaiphragm (in CXR) CT myelographyCT myelography


In the histamine test axon reflex i.e. In the histamine test axon reflex i.e. flare will be absent only in post flare will be absent only in post ganglionic lesionsganglionic lesions

EMG will show denervating potentials EMG will show denervating potentials in the segmental paraspinal muscles in the segmental paraspinal muscles supplied by the posterior primary ramisupplied by the posterior primary rami

NCS will show retained motor & absent NCS will show retained motor & absent sensory conductionsensory conduction

Sensory action potentials will be Sensory action potentials will be presentpresent


Sensory evoked potentials will also Sensory evoked potentials will also be presentbe present

CT myelography- done after 6-12 CT myelography- done after 6-12 weeks to allow dissolution of blood weeks to allow dissolution of blood clots will show clots will show pseudomeningocoele/absence of pseudomeningocoele/absence of nerve root shadow at lesion sitenerve root shadow at lesion site

Other suggestive features areOther suggestive features are Involvement of all 5 rootsInvolvement of all 5 roots Severe pain in anaesthetic armSevere pain in anaesthetic arm Posterior triangle bruising and Posterior triangle bruising and

supraclavicular sensory losssupraclavicular sensory loss Transverse process fractureTransverse process fracture Horners syndromeHorners syndrome

Brachial neuritisBrachial neuritis

Also called brachial plexitis/ plexopathy Also called brachial plexitis/ plexopathy /neuralgic amyotrophy/parsonage-/neuralgic amyotrophy/parsonage-turner syndrometurner syndrome

Presents abruptly in a normal individualPresents abruptly in a normal individual Usually a male in his 3-7Usually a male in his 3-7thth decade decade 1/31/3rdrd it is bilateral it is bilateral Severe neck/shoulder/arm/scapular Severe neck/shoulder/arm/scapular

pain that may last hours to weekspain that may last hours to weeks

Brachial..Brachial..

Followed by severe muscle weakness Followed by severe muscle weakness and wastingand wasting

Less of sensory changesLess of sensory changes Maybe a h/o preceding Maybe a h/o preceding

infection/immunizationinfection/immunization Recovers over monthsRecovers over months EMG & NCS help in c.f from root EMG & NCS help in c.f from root

lesionlesion

Thoracic outlet syndromeThoracic outlet syndrome

Due to compression of neurovascular Due to compression of neurovascular structures at the thoracic outlet structures at the thoracic outlet bounded by the 1bounded by the 1stst rib, clavicle & rib, clavicle & scalene musclesscalene muscles

3 types3 types True neurogenic TOSTrue neurogenic TOS

Upper cord compressionUpper cord compression Lower cord compressionLower cord compression

Vascular TOSVascular TOS Disputed TOSDisputed TOS

TOS..TOS.. Of these upper cord compression Of these upper cord compression

neurogenic TOS can present as neurogenic TOS can present as neck/face/shoulder/ arm pain with neck/face/shoulder/ arm pain with features of C5,C6,C7 involvementfeatures of C5,C6,C7 involvement

Associated maybe features of Associated maybe features of ischaemia/ embolization/venous ischaemia/ embolization/venous compressioncompression

Usually occurs in young to middle Usually occurs in young to middle aged femalesaged females

Tests areTests are Adsons testAdsons test Military testMilitary test Hyperabduction manouverHyperabduction manouver EAST (Roos test)EAST (Roos test)

TOS Contd..TOS Contd..

Adsons, military & hyperabduction tests Adsons, military & hyperabduction tests are for the vascular component ,EAST is are for the vascular component ,EAST is what concerns uswhat concerns us

The patient is asked to slowly open and The patient is asked to slowly open and close his hands while keeping the arm close his hands while keeping the arm abducted, externally rotated and flexed abducted, externally rotated and flexed to 90 degrees at the elbow for 3 to 90 degrees at the elbow for 3 minutesminutes

Normal patients experience only Normal patients experience only fatigue, neurogenic TOS patients fatigue, neurogenic TOS patients experience pain & parasthesiae experience pain & parasthesiae

TOS Contd..TOS Contd..

Investigated byInvestigated by X ray cervical spineX ray cervical spine EMG/NCS – which show prolonged EMG/NCS – which show prolonged

conduction times. Somatosensory conduction times. Somatosensory evoked potentials can be used to locate evoked potentials can be used to locate site of lesionsite of lesion

WhiplashWhiplash

Two typesTwo types Hyperextension injury/acceleration Hyperextension injury/acceleration

injury/rear end collision injuryinjury/rear end collision injury Hyperflexion injury/decceleration Hyperflexion injury/decceleration

injury/front end collision injuryinjury/front end collision injury

Hyperextension injury Hyperextension injury mechanismmechanism

Rear impact Rear impact neck hyperextension neck hyperextension protective flexor muscle spasm protective flexor muscle spasm which unfortunately acts as a which unfortunately acts as a compressive force along the cervical compressive force along the cervical spine resulting in compressive spine resulting in compressive hyperflexionhyperflexion

Hyperflexion injury Hyperflexion injury mechanismmechanism

Front end collision Front end collision hyperflexion hyperflexion protective extensor muscle spasmprotective extensor muscle spasm hyperextensionhyperextension

NEWEST CONCEPTNEWEST CONCEPT

Findings in whiplash radicular Findings in whiplash radicular damagedamage

Neck rigidity & limited extensionNeck rigidity & limited extension Limited rotation to side of injuryLimited rotation to side of injury Pain & parasthesiae aggravated by Pain & parasthesiae aggravated by

cough/sneezecough/sneeze Tenderness over affected vertebraeTenderness over affected vertebrae Parasthesiae along affected nerve rootsParasthesiae along affected nerve roots Pain and tenderness along affected Pain and tenderness along affected

myotomemyotome

Findings..Findings..

Weakness of supplied musclesWeakness of supplied muscles Depressed reflexes of corresponding Depressed reflexes of corresponding

rootroot

INJURIES TO C1, C2INJURIES TO C1, C2

Facet dislocationFacet dislocation If on cervical spine lateral view the If on cervical spine lateral view the

dislocation of the vertebral body is ,1/2 dislocation of the vertebral body is ,1/2 of its AP diameter it is U/L facet of its AP diameter it is U/L facet dislocationdislocation

If dislocation is >1/2 it is B/L facet If dislocation is >1/2 it is B/L facet dislocation dislocation

Facet injury is responsible for pain in Facet injury is responsible for pain in 50-60% cases of whiplash50-60% cases of whiplash

Post-traumatic headaches in 33%Post-traumatic headaches in 33% Usually at C2-C3 & C5-C6 levelsUsually at C2-C3 & C5-C6 levels

Sympathetic nervous system Sympathetic nervous system injuryinjury

Called Barre-Lieou syndromeCalled Barre-Lieou syndrome Injury can occur atInjury can occur at

Posterior cervical sympatheticsPosterior cervical sympathetics Sensory elements of C1,C2Sensory elements of C1,C2 Irritation of nerve root at neuroforamenIrritation of nerve root at neuroforamen Compression of vertebral arteryCompression of vertebral artery Encroachment of basilar veinsEncroachment of basilar veins

Barre-Lieou syndromeBarre-Lieou syndrome

Characterized byCharacterized by Aural-tinnitus/deafness/postural dizzinessAural-tinnitus/deafness/postural dizziness Ocular-blurring/retro bulbar pain/pupil Ocular-blurring/retro bulbar pain/pupil

dilatation on turning to affected sidedilatation on turning to affected side Other-corneal hypoesthesia/ miosis/ Other-corneal hypoesthesia/ miosis/

rhinnorrhea/ sweating/ lacrimation/ rhinnorrhea/ sweating/ lacrimation/ photophobia/ cranial nerve dysfunction/ photophobia/ cranial nerve dysfunction/ hoarseness/ aphonia/ upper extremity hoarseness/ aphonia/ upper extremity dysesthesiadysesthesia

Barre lieou..Barre lieou..

This is because the cervical This is because the cervical sympathetics contribute to carotid sympathetics contribute to carotid plexus, brachial plexus, cardiac plexus, brachial plexus, cardiac plexus, aortic plexus & phrenic plexus, aortic plexus & phrenic plexusplexus

Central cord syndromeCentral cord syndrome

h/o rear end collision in an elderly h/o rear end collision in an elderly subjectsubject

No head collision/LOCNo head collision/LOC Sudden hyperextensionSudden hyperextension Numbness of whole trunk and Numbness of whole trunk and

extremityextremity Inability to move arms/legsInability to move arms/legs Inability to voidInability to void

Central cord..Central cord..

O/E O/E Motor weakness of UL>LLMotor weakness of UL>LL Sensory loss below level of lesionSensory loss below level of lesion Bladder dysfunction Bladder dysfunction

Thought to be due to Thought to be due to Contusion of cordContusion of cord Transient ischaemic damage to cordTransient ischaemic damage to cord


Cord contusion is due to squeezing of Cord contusion is due to squeezing of the cord between hypertrophic spur the cord between hypertrophic spur anteriorly & ligamentum flavum anteriorly & ligamentum flavum posteriorlyposteriorly

Ischaemia is thought to be due to Ischaemia is thought to be due to vertebral artery being affected atvertebral artery being affected at Atlanto-axial jointAtlanto-axial joint Atlanto-occipital jointAtlanto-occipital joint # dislocation above c6# dislocation above c6


In contusion there is both motor & In contusion there is both motor & sensory losssensory loss

In vascular injury usually sensory loss In vascular injury usually sensory loss is minimal/absent with mainly motor is minimal/absent with mainly motor lossloss

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Approach to neck pain

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