2. In General
Difficult to arrive at an anatomical
diagnosis
Most important is to be able to recognize a
serious pain state
Differentiate neck pain due to common
diseases from neck pain due to local
pathology
3. EPIDEMIOLOGY
Very common; 2 out of 3 people
experience neck pain at some point in life
High among the working aged populace
Incidence in general populace is 10-20%
25-40% complain of associated radiation
to upper extremity
4. Epidemiology..
In the population>45 yrs old >50% have
neck pain/stiffness
Incidence is higher in women & 30-50
year old adults
Whiplash injuries are a common cause
5. RTA & Whiplash
62% of RTA victims have whiplash
33-66% develop symptoms within 24
hours
30-42% have continued intermittent pain
at 1 year
6% have continuous pain at 1 year
28% have chronic pain
11. Examination
History
Onset-Acute or Insidious?
Site of pain
Character
Radiation
Radiation- Dermatomal or diffuse?
Aggravating factors and relieving factors
Prior trauma
12. History..
Joint pain?
Prior general diseases?
General symptoms- fever ,weight loss etc.
Symptoms of neurological complications-
weakness, parasthesiae, gait disorders,
vertigo, visual disturbances
15. Examination..
Movements
Flexion
Extension
Lateral flexion
Rotation
Check for active and passive motion
The shoulders should be horizontal while
testing for movements
Normally the chin can touch the chest
16. Examination..
If lateral flexion cannot be carried out
without forward flexion this shows
involvement of the first two joints
When checking for rotation the shoulder
should be restrained by the physician
1/3 rd of rotation occurs at the first two
joints
The nose & forehead should be in the
horizontal plane on full extension
1/5 th of flexion-extension & lateral rotation
occur at the first two joints.
17. Examination..
When checking for passive motion place
the patient erect on a stool. standing
behind the patient the left hand stabilizes
the shoulder blades in the horizontal plane
while the left test for extension and
rotation starting from the neutral.
When testing for flexion the hands are
reversed.
18. Normal range of motion
Flexion :80°
Extension :50°
Lateral flexion :45°
Rotation :80° to either side
19. Examination..
If there is pain try to differentiate whether
pain arises from the neck or shoulder or
both.
Reflex muscle spasm due to pain will
cause limitation of movements but this
can be overcome passively
If real limitation of movements persists it
indicates structural damage within the
corresponding joints.
20. Examination..
Mechanical problems usually cause
asymmetric limitation of movement
Inflammatory/ Neoplastic disorders on the
other hand are widespread and more or
less symmetric ; hence pain & movement
restriction will also be symmetric
25. Examination..
Specific tests
C1-C7 neurological exam & further as req.
Crepitus
Cervical rib
Radiculopathy
Myelopathy
26. Neurological exam
C1-C4 involvement will show no motor weakness
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
27. Examination..
It is possible to test the sensory supply of
C2-C4
Neck flexion/lateral flexion are by C2,C3 &
spinal accessory
Neck extension is by C3,C4,spinal
accessory & the posterior rami of spinal
nrves
Trapezius reflex is mediated by C3,C4
28.
29. Specific..
Crepitus
Spread both hands on either side of the neck
and ask patient to flex and extend the neck.
Facet joint crepitus-a common finding in
spondylosis is felt
If in doubt auscultate
31. Specific..
Cervical rib
Look for vascular deficits in the upper limb
Adsons test-patient takes a deep breath and
turns his head toward the side of the lesion;
watch for radial pulse obliteration or decrease
Auscultate over supraclavicular area to check
for murmur of subclavian artery compression
32. Specific..
Radiculopathy
Lateral stretch test
Cervical compression test/anvil test/Spurlings
test
Distraction test
Shoulder abduction relief test
Tinels sign
Upper limb tension tests
33. Radiculopathy..
Lateral stretch test
Stretching of the neck in the opposite
direction will elicit pain along the nerve root
distribution
34. Contd..
Spurlings test
Sit the patient on a stool with head in
neutral position & with the head in 45
degree rotation to either side with the
head tilted toward the ceiling.
In each of these three positions apply
brisk compression in the line of the
spine standing behind the patient.
If the patient suffers from foraminal
stenosis of any cause there will be
root pain along the distribution of the
concerned root
36. Radiculopathy..
Distraction test
Passively elevating the head in the
neutral position by holding it at the
occiput and chin will relieve
symptoms
38. Radiculopathy..
Shoulder abduction relief test
Significant relief of pain with shoulder
abduction
Seen in soft cervical disk prolapse
Negative in radiculopathy due to
spondylosis
39. Radiculopathy..
Tinels sign
In radiculopathy direct palpation or
percussion over the exiting nerve
root may provoke the patients typical
pain
If it is found to be positive more
laterally ,such as over the
supraclavicular fossae then the
diagnosis should be questioned
51. Radiculopathy..
Radiculopathy may be associated with
myelopathy
Can involve one or multiple roots
Findings may overlap due to intraneural
intersegmental connections of sensory nerve
roots
52. Radiculopathy..
Neurological findings suggestive of
radiculopathy besides the above signs are
Pain/ parasthesiae aggravated by
coughing/sneezing
Parasthesiae along nerve root distribution
Pain & tenderness along muscles of the
involved myotome
Weakness of said muscles
Depressed reflexes corresponding to the
involved root
Basically LMN signs.
53. Specific..
Myelopathy
LMN signs in the upper limbs at the
level of compression (flaccid paralysis,
muscle atrophy, absent reflexes)
UMN signs below the level of the
lesion, mainly evident in the lower
limbs. (hypertonicity, hyperreflexia,
clonus, Babinskis sign)
Sensory deficit is non dermatomal
involving large areas e.g.-whole
arm/forearm/wrist
Bladder involvement may be present
Funicular pain (burning pain)
54. Other signs of myelopathy
Hoffman's test/dynamic Hoffmann's
test
Lhermittes sign
Inverted supinator jerk/inverted
radial reflex
Clonus
Myelopathy hand
Gait abnormalities such as ataxic
broad based shuffling gait
55. Myelopathy..
Hoffmann's test
Rapidly extend the distal phalanx of the
middle finger by flicking its pulp
Positive if there is flexing of the IP joints of
the index & thumb
Dynamic Hoffmann's test
Repeat while the patient flexes & extends the
neck which facilitates the response
56.
57. Myelopathy..
Lhermittes test
Flexion or extension produces electric shock
like sensations , particularly in the legs.
Inverted supinator jerk
While eliciting the brachioradialis jerk instead
of brachioradialis contraction we get flexion of
the fingers of the hand
Highly specific for lesion at C5
58. Myelopathy..
Myelopathy hand
Kinetic
Inability to flex & extend the fingers rapidly
Time over 10 seconds
Usually in excess of 20 cycles
Postural
Deficient adduction & often extension of
the ulnar 1-3 fingers
59. Myelopathy..
In the mildest cases when the fingers are
extended the little finger lies slightly in
abduction; even if adduction is possible it
cannot be held for long. abduction is
normal (finger escape sign)
If severe the little, ring & sometimes the
middle finger may abduct and/or the same
fingers may flex & loose their power of
extension.
Myelopathy is most common at C5 ,first
affecting deltoid & infraspinatus
60.
61. Myelopathy..
Motor weakness when present is
asymmetric & usually affects multiple
levels
Vibration & position sense are often
reduced
Babinskis sign becomes positive only late
in the disease
62. Myelopathy..
Any lesion which compresses the cord can
cause myelopathy but in particular
consider
Canal stenosis
Spondylosis
Cervical kyphosis
Old dens # non union
Investigated best by CT myelography, MRI
or dynamic MRI
64. How to differentiate the source of
neck pain
Pain from joints
ligaments/muscles
c/o pain & stiffness
Deep, dull aching &
often episodic pain
h/o
excessive/unaccustom
ed activity or of
sustaining an
awkward posture
Pain from nerve
roots or the spinal
cord
c/o root pain
Sharp, intense often
burning pain
Radiates to trapezial,
interscapular areas or
down the arm
65. Differentiation Contd..
No h/o injury
Localized asymmetric
pain
Upper cervical pain is
referred to the head,
lower cervical to the
arm
Aggravated by
movement, relieved
by rest
Numbness & motor
weakness in a
myotomal distribution
Headache may occur
with upper root
involvement
Symptoms aggravated
by neck
hyperextension.
66. When to suspect serious disease
Unrelenting symptoms and pain radiating
to both hands
Systemic causes such as
Ankylosing spondylitis
Polymyalgia
Malignancy/myeloma/metastasis
Osteomyelitis/tuberculosis
Myelopathy
Progressively increasing pain c.f episodic
67. Is the patient faking?
Non-organic signs of Waddell
Nonanatomic tenderness
Simulation sign
Distraction sign
Regional motor or sensory disturbance
Overreaction
68. Waddell's signs
Their interpretation depends on the
experience of the physician with a wide
range of patients
The signs are significant when more than
one are present in the same patient
The most sensitive sign is overreaction
69. Nonanatomic tenderness
Said to be present when the patient
complains of pain with extremely light
touch or tenderness whose distribution
does not conform to the distribution of
known anatomic structures
Verified by palpating areas that are not
usually tender
CRPS is an exception
70. Simulation sign
Positive under two circumstances
Patient c/o pain along the whole length of
spine or in the lower back in response to
spurlings test
Patient c/o pain when the rotation
simulation maneuver is done i.e head &
shoulders are rotated in a manner
coplanar with the pelvis
71. Distraction sign
Pertinent only in case of back pain
Patient c/o pain in the SLR test but fails to
do so when the knee is extended from the
seated position
72. Regional motor/sensory
disturbance
Regional sensory disturbance exists when
there is sensory disturbance in a
nonanatomic distribution such as glove &
stocking distribution
Regional motor disturbance is suspected if
there is diffuse weakness in multiple
muscle groups/in the whole limb etc or if
the examiner feels that the patients
muscles give way in an unphysiological
manner during strength testing
73. Overreaction
Present when the patient reacts physically
or verbally in an inappropriately theatrical
manner in response to light palpation or
gentle methods of examination
76. Investigations..
X rays AP, lateral, oblique
More useful when acute severe injury is
suspected
Tumors, infections are other instances
Oblique view shows foramina
Stress x rays
Used to demonstrate spinal instability in
patients without neurological deficits whose
plain films show no findings
77. Investigations..
CT
Detects # missed by x rays
Useful in assessing spinal canal/foramina
MRI
Helps in diagnosing disc rupture/herniation
Intraspinal soft tissue processes e.g.-
intra/epidural abscesses, hematomas,
Intraspinal tumors
78. Investigations..
Degenerative disc changes present in 25% of
asymptomatic adults under 40 yrs,60% of
those over 40 years & 70% of those over 70
yrs
79. Investigations..
Myelography/contrast CT
To study the relation between bony & neural
structures for pre-op planning
Nerve blocks
Facet block/cervical sympathetic
blocks/trigger point blocks etc help to
diagnose the site of lesion as well as being
therapeutic occasionally
80. Investigations..
Discography
May help in identifying the affected disc
May identify disc rupture missed by MRI
However the risks generally outweigh the
benefits.
Nerve conduction studies/electromyography
Help confirm radiculopathy
Only way to diagnose C3,C4 radiculopathy is
EMG
87. Torticollis (Wry neck)
Rotational deformity of upper cervical
spine causing turning & tilting of the head
Head tilted to involved side & chin to
opposite side
Due to wide number of causes
Congenital
Neurologic
Inflammatory
Traumatic
88. Torticollis..
Congenital may be due muscular wry neck
or due to anomalies of upper cervical
spine like klippel-feil syndrome, basilar
impression, odontoid anoimalies, Atlanto-
occipital fusion etc
Neurologic abnormalities like ocular
dysfunction, syrigomyelia,s.cord/cerebellar
tumors can lead to torticollis
89. Torticollis..
Inflammation can cause torticollis such as
cervical lymphadenitis, rotatory
subluxation of childhood
Trauma of any sort to upper spine
especially C1-C2 is another cause
90. Tension neck
Patient c/o neck pain usually in the
suboccipital & posterior aspects
Muscle tenderness will be present
H/o stress/holding head in abnormal
position/unaccustomed work/faulty
posture will be present
Pain may radiate to scalp due to irritation
of superior occipital nerve
91. Fibromyalgia
Clinical syndrome charachterized by
diffuse vague pain, extreme fatigue,
stiffness, tender points, sleep disturbance
Thought to be due to disturbance in stage
4 NREM sleep
Diagnosed by
h/o widespread pain especially shoulder/pelvic
girdle
Pain at 11 out of 18 tender points on 4 kg
force
93. Fibromyalgia Contd..
Pain in muscles & joints
Worst in the morning
muscle tone, breakaway weakness,
livedo reticularis may be present
Joints are not tender.
Skin fold roll test-rolling of skin fold at T12
level from below upwards will cause
severe pain
94. Myofascial pain syndrome
Diagnosis is made when on examination
we find trigger points in the affected
muscles
Trigger points are tender knotted points
that on palpation will cause pain at a
different site
Infiltration with lignocaine is useful both
as a diagnostic & therapeutic test
95. Cervical Spondylosis
Actually is a combination of degenerative
& herniated IVDP
Also called osteoarthritis, osteoarthrosis,
chronic herniated disk, chondroma, spur
formation, osteophytosis
Seen in 75% of those .65yrs old
May present as neck pain & myelopathy
,Neck pain & radiculopathy or progressive
myelopathy
96. Spondylosis..
Radiculopathy due to osteophytes
Myelopathy due to stenosis, osteophytes &
PLL calcification
Most commonly affects C5-C6,C6-C7 & C4-
C5
Occiput to C3 involvement is uncommon
Vertebral artery maybe involved in the
transverse foramen
97. Spondylosis..
Arthritis of facet joints or joints of Luschka
can cause pain
Disk degeneration leads to IVDP
Cervical Spondylosis without pain is similar
to Multiple sclerosis (involvement above
f.magnum), Amyotrophic lateral sclerosis
(no sensory changes, mixed UMN & LMN
of all limbs), Syringomyelia and spinal cord
tumor
98. Spondylosis..
When there is cervical IVDP pain is a poor
guide to localization, sensory/motor loss &
reflex changes are a better guide
1/4th have sensory loss
1/3rd have subjective weakness
3/4th have objective weakness
99. Cervical canal stenosis
Risk of spinal cord injury is greater if trauma
occurs
Torg ratio
Diameter of canal: width of cervical body (AP)
<0.8 indicates stenosis
Pavlov ratio
Canal: vertebral body width
Normally 1 ,<0.85 stenosis,<0.8 high risk for
later injury-it also indicates congenital stenosis
Absolute stenosis-AP diameter<10mm
Relative stenosis-AP diameter10-13 mm (normal
is 17)
100. Spinal cord lesions
Produce deep, constant, progressive pain
not by coughing/sneezing
Spinal epidural abscess starts as localized
,boring pain which leads to muscle spasm
& cervical rigidity rapidly progressing to
cord progression. MRI is the investigation
of choice
101. Cord lesions..
Spinal epidural hemorrhage presents as
sudden severe pain with radicular
component and respiratory distress.50%
have motor symptoms in 12 hours.15%
are due to trauma. Investigated best by
MRI/CT
102. Herpes zoster
Usually affects 1 root occasionally 2-3
roots
Usually vesicles appear first then pain
Severe lancinating pain
Involves only one side of the body
In C2 involvement the pain appears first
as the vesicles are hidden by the hair/ear
Motor weakness in 60%
103. Syringomyelia
Due to disturbed hydrodynamics of spinal
fluid resulting in central syrinx formation
More common in thoracic than cervical
area
Maybe idiopathic, traumatic or associated
with spinal cord tumor
Idiopathic form associated with Arnold –
Chiari malformations
104. Syringomyelia..
Occurs in 1-3 % of spine trauma
Presents as radicular pain, spasticity,
dissociative anaesthesia in the form of
“cape” sensory loss, LMN signs at the level
of the syrinx (usually the arms)
If ir enlarges then UMN LL sings develop
25-80% have left thoracic scoliosis
MRI is investigation of choice
105. Brachial plexus pathology
Two types of brachial plexus pathology
cause neck pain
Preganglionic plexus injuries
Brachial neuritis
106. Preganglionic brachial plexus
lesions
Can cause severe pain along the neck
,shoulder & arm with an anaesthetic limb
when the upper plexus is involved
Look for features of C5, C6 involvement by
examining myotomes and dermatomes.
C5 myotome is mainly deltoid, dermatome
is lower deltoid
C6 myotome is tested by testing for
supination/ pronation, dermatome is index
finger
107. Preganglionic..
Reflexes affected are biceps &
brachioradialis
Preganglionic nature is diagnosed by
Nerve to serratus anterior involvement
Dorsal scapular nerve involvement (Levator
scapulae & rhomboids)
Long tracts of spinal cord involvement
Retention of sensory conduction in the
presence of sensory loss
109. Preganglionic..
In the histamine test axon reflex i.e. flare
will be absent only in post ganglionic
lesions
EMG will show denervating potentials in
the segmental paraspinal muscles supplied
by the posterior primary rami
NCS will show retained motor & absent
sensory conduction
Sensory action potentials will be present
110. Preganglionic..
Sensory evoked potentials will also be
present
CT myelography- done after 6-12 weeks to
allow dissolution of blood clots will show
pseudomeningocoele/absence of nerve
root shadow at lesion site
111. Other suggestive features are
Involvement of all 5 roots
Severe pain in anaesthetic arm
Posterior triangle bruising and supraclavicular
sensory loss
Transverse process fracture
Horners syndrome
112. Brachial neuritis
Also called brachial plexitis/ plexopathy
/neuralgic amyotrophy/parsonage-turner
syndrome
Presents abruptly in a normal individual
Usually a male in his 3-7th decade
1/3rd it is bilateral
Severe neck/shoulder/arm/scapular pain
that may last hours to weeks
113. Brachial..
Followed by severe muscle weakness and
wasting
Less of sensory changes
Maybe a h/o preceding
infection/immunization
Recovers over months
EMG & NCS help in c.f from root lesion
114. Thoracic outlet syndrome
Due to compression of neurovascular
structures at the thoracic outlet bounded
by the 1st rib, clavicle & scalene muscles
3 types
True neurogenic TOS
Upper cord compression
Lower cord compression
Vascular TOS
Disputed TOS
115. TOS..
Of these upper cord compression
neurogenic TOS can present as
neck/face/shoulder/ arm pain with
features of C5,C6,C7 involvement
Associated maybe features of ischaemia/
embolization/venous compression
Usually occurs in young to middle aged
females
Tests are
Adsons test
Military test
Hyperabduction manouver
EAST (Roos test)
116. TOS Contd..
Adsons, military & hyperabduction tests
are for the vascular component ,EAST is
what concerns us
The patient is asked to slowly open and
close his hands while keeping the arm
abducted, externally rotated and flexed to
90 degrees at the elbow for 3 minutes
Normal patients experience only fatigue,
neurogenic TOS patients experience pain
& parasthesiae
117. TOS Contd..
Investigated by
X ray cervical spine
EMG/NCS – which show prolonged conduction
times. Somatosensory evoked potentials can
be used to locate site of lesion
118. Whiplash
Two types
Hyperextension injury/acceleration injury/rear
end collision injury
Hyperflexion injury/decceleration injury/front
end collision injury
119. Hyperextension injury mechanism
Rear impact neck hyperextension
protective flexor muscle spasm which
unfortunately acts as a compressive force
along the cervical spine resulting in
compressive hyperflexion
127. Findings in whiplash radicular
damage
Neck rigidity & limited extension
Limited rotation to side of injury
Pain & parasthesiae aggravated by
cough/sneeze
Tenderness over affected vertebrae
Parasthesiae along affected nerve roots
Pain and tenderness along affected
myotome
131. Facet dislocation
If on cervical spine lateral view the
dislocation of the vertebral body is ,1/2 of
its AP diameter it is U/L facet dislocation
If dislocation is >1/2 it is B/L facet
dislocation
Facet injury is responsible for pain in 50-
60% cases of whiplash
Post-traumatic headaches in 33%
Usually at C2-C3 & C5-C6 levels
132. Sympathetic nervous system injury
Called Barre-Lieou syndrome
Injury can occur at
Posterior cervical sympathetics
Sensory elements of C1,C2
Irritation of nerve root at neuroforamen
Compression of vertebral artery
Encroachment of basilar veins
133. Barre-Lieou syndrome
Characterized by
Aural-tinnitus/deafness/postural dizziness
Ocular-blurring/retro bulbar pain/pupil
dilatation on turning to affected side
Other-corneal hypoesthesia/ miosis/
rhinnorrhea/ sweating/ lacrimation/
photophobia/ cranial nerve dysfunction/
hoarseness/ aphonia/ upper extremity
dysesthesia
134. Barre lieou..
This is because the cervical sympathetics
contribute to carotid plexus, brachial
plexus, cardiac plexus, aortic plexus &
phrenic plexus
135. Central cord syndrome
h/o rear end collision in an elderly subject
No head collision/LOC
Sudden hyperextension
Numbness of whole trunk and extremity
Inability to move arms/legs
Inability to void
136. Central cord..
O/E
Motor weakness of UL>LL
Sensory loss below level of lesion
Bladder dysfunction
Thought to be due to
Contusion of cord
Transient ischaemic damage to cord
137. Central cord..
Cord contusion is due to squeezing of the
cord between hypertrophic spur anteriorly
& ligamentum flavum posteriorly
Ischaemia is thought to be due to
vertebral artery being affected at
Atlanto-axial joint
Atlanto-occipital joint
# dislocation above c6
138. Central cord..
In contusion there is both motor &
sensory loss
In vascular injury usually sensory loss is
minimal/absent with mainly motor loss