Neck Pain
What is in…
• Cervical spondylosis
• Cervical spondylitis
• Cervical spondylolisthesis/disk bulges
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What is it?
Causes
Risk factors
Symptoms
Signs
Complications
Tests
Pharmacological/surgical management
Physiotherapy management
Cervical Spondylosis
• CS is a disorder in which there is abnormal wear on
the cartilage and bones of the cervical vertebrae
• A common cause of chronic neck pain
Causes
• CS is caused by chronic wear on the cervical spine
• This includes the disks
between the neck vertebrae
and the joints between the
bones of the cervical spine
• There may be abnormal
growths or "spurs" on the
vertebrae
• These changes can, over time,
compress one or more of the nerve
roots. In advanced cases, the spinal
cord becomes involved
• Everyday wear and tear may
start these changes
• People who are very active at
work or in sports may be
more likely to have them
Risk factors
• The major risk factor is aging
{by age 60, most women and
men (men>women) show signs of
CS on x-ray}
• Being overweight and not exercising
• Having a job that requires heavy lifting or a lot of
bending and twisting
• Past neck injury (often several years before)
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Past spine surgery
Ruptured or slipped disk
Severe arthritis
Small fractures to the spine
from osteoporosis
• Congenital deformity
Symptoms
• Neck or shoulder pain, stiffness of the neck, and
difficulty turning or bending the neck from side-toside
• Symptoms may get worse with turning, extending, or
bending the neck
• Pain that shoots down the arm, and numbness,
weakness, or pains in the arm
• Muscles spasm and popping sound
near the neck
• Symptoms are caused by imposition on the spinal
cord or the nerves as they exit the spine, or both
• A stiff neck is most often one of the very first signs
• Neck stiffness tends to grow progressively worse
over time
• Radiating pain (stabbing, burning, or dull ache) to the
bottom of the skull and/or to the shoulder and down
the arm
• Can be accompanied by paresthesias and muscle
weakness in the neck, shoulders, arms, and hands;
numb, clumsy hands syndrome
Patterns of CS
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Radicular pattern
Vertebral artery pattern
Myelopathy pattern
Sympathetic pattern
Combination pattern
Pathology – radicular pattern
• Posterolateral protrusion of the cervical disc
• Hyperplacia, hypertrophy of the facet joint
• Stimulate or compress nerve roots as they emerge
from the cord to pass peripherally through the
intravertebral foramen
Clinical manifestation
• Symptoms
– Neck pain: radiating to the ipsilateral upper extremity
– Paresthesia
– Muscle weakness in appropriate distribution
• Pain and paresthesia may be intensified by neck
movement, especially by extension or lateral flexion
to the side of the herniation
• May be improved by traction on the neck
• Signs
– Stiffness of the neck
– Tenderness, spasm of paraspinous muscles
– Limitation of active and passive motion of the neck and
affected upper extremity
Radiographic studies
Pathology – myelopathy pattern
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Midline herniation of nucleus pulposus
Osteophyte of posterior rims of vertebral body
Hyperplasia of the ligamentum flavum
Calcification of the posterior longitudinal ligament
• These all lead to compression of the spinal cord
Clinical manifestation
• Symptoms
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Weakness
Loss of balance
Cannot handle small objects
Neck pain not obvious
Numbness
Dysfunction of upper motor neuron is gradually present
from the lower part of the body to the upper
– Spastic paraplegia or quadriplegia
– Loss of control of the bladder or bowels
Signs - CSM
• Marked motor and relatively few sensory changes
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Hypertonicity
Hyperreflexia
Patellar clonus (+)
Ankle clonus (+)
• Pyramidal tract sign
– Hoffmann’s sign
– Babinski’s sign
– Obstacle of fine motion of the fingers,
such as buttons or writing
Calcification of the posterior
longitudinal ligament
MRI
Pathology – vertebral artery pattern
• Hyperplasia, stenosis of cervical vertebral transverse
foramen, hypertrophy of articular process, unstable
cervical vertebra
• Directly stimulate, compress vertebral artery
Clinical manifestation
• Symptoms
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Vertigo is main, induced by rotating neck
Migraine
Sudden blackout/diplopia, recovered in a short time
Cataplexy caused by sudden spasm of artery due to
stimulation, come to normal at once after falling to the
ground
• Sign
– Positive neck rotation test
Differential diagnoses
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Adhesive capsulitis
Brown-Sequard syndrome
Carpal tunnel syndrome
Central cord syndrome
Cervical disc disease
Cervical myofascial pain
Chronic pain syndrome
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Diabetic neuropathy
Multiple sclerosis
Myofascial pain
Neoplastic brachial plexopathy
Osteoporosis and spinal cord injury
Radiation-induced brachial plexopathy
Rheumatoid arthritis
Traumatic brachial plexopathy
Signs – summary
• An examination may show that patient has trouble
moving head toward shoulder and rotating head
• Ask patient to bend head forward and to the sides
while putting slight downward pressure on the top of
the head - increased pain or numbness during this
test is usually a sign that there is pressure on a nerve
in patient’s spine
• Weakness or loss of feeling can be signs of damage
to certain nerve roots or to the spinal cord (reflexes
are often reduced)
Special tests
• Cervical range of motion
– The patient is seated and cervical rotation is measured with a standard
goniometer
– Considered positive if the patients ipsilateral cervical rotation is less
than 60°
• Upper limb tension test
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Considered positive if:
1) Symptoms are reproduced
2) Side-to-side differences in elbow extension are greater than 10°
3) If contralateral lateral flexion of the cervical spine increases
symptoms or ipsilateral lateral flexion decreases symptoms
Upper limb tension test
• Axial loading
– Spurling maneuver
– Lateral flexion and extension of the neck, and then axial pressure on
the spine
• Neck distraction/axial manual traction test
– One hand under the patient’s chin and the other hand around the
occiput, then slowly lift the patient’s head as axial traction force is
gradually applied up to 30 pounds
– Positive if the pain is relieved when the head is distracted
• Shoulder abduction
– Place the hand of the affected extremity on the head
– A positive response is alleviation of patient symptoms
Cervical distraction
Spurling’s compression
Shoulder abduction
Sensitivity & Specificity Of Tests -
(according To Viikari-Juntura et al)
Test
Position
Sensitivity
Specificity
Spurling
Compression
Seated
40-60%
92-100%
Shoulder
Abduction
Seated
43-50%
80-100%
Neck
Distraction
Supine (1015kg)
40-43%
100%
Other special tests
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2.
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Tension arm test
Percussion head test
Jackson test
Compression shoulder test
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Vertebrobasilar circulation assessment
• Vascular Insufficiency may be aggravated by
positional change in the cervical spine
• Assessment of the vertebrobasilar circulation must
be done if cervical adjustment or manipulation is to
be performed
• Positional change in the cervical spine compresses
the vertebral artery at the atlantoaxial junction on
the side opposite of rotation
Testing
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Barre-Lieou sign
Maigne’s test
Dekleyn’s test
Hautant’s test
Underburg’s test
Hallpike’s maneuver
Complications
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Chronic neck pain
Progressive loss of muscle function or feeling
Poor balance
Permanent disability (occasionally)
Use of a neck brace to immobilize the neck
Inability to retain feces
Urinary incontinence
Diagnostic tests - Imaging
• Neck x-ray (lateral)
– Bony outgrowths at the margin of the joints
– Reduced space between the vertebrae of neck
– Narrowed opening between the bones
• CT scan
• MRI of the neck (when there is severe pain, weakness, numbness)
– Loss of normal curvature of neck
– Vertebral bone canal diameter is decreased
– Spinal canal is narrowed
Cervical x-ray
Cervical MRI
Nerve function tests - Diagnostic tests
• Electromyelogram (EMG)
• Nerve conduction velocity test
Pharmacological/surgical management
• Treatment is aimed at relieving pain and preventing
permanent spinal cord and nerve root injury
• Treatments include:
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Anti-inflammatory medication (NSAIDs)
Cortisone injections
Narcotics or opioids (if pain is very severe)
Cognitive behavioral therapy (talk therapy) may be helpful
if the pain is having a serious impact on life (helps better
understand pain and teaches how to manage it)
– Surgery to remove bone and disc tissue to relieve the
pressure on the nerves or spinal cord (foraminotomy,
laminectomy, spinal fusion)
Foraminotomy
Laminectomy
Spinal fusion
Physiotherapy management
• Cervical traction
• Postural education
• Exercises
– Stretching
– Strengthening
• Manual therapy
• Cold packs and heat therapy
Tips to a healthier neck
• Always stretch before exercise or other strenuous
physical activity
• At home or work, make sure the work surface is at a
comfortable height
• Don’t lean when standing or sitting. When standing keep
the weight balanced on the feet.
• Sit in a chair with good lumbar support and proper
position and height for the task. Keep the shoulders back.
Switch sitting positions often and periodically walk
around the office or gently stretch muscles to relieve
tension. If one must sit for a long period of time, rest the
feet on a low stool.
• Wear comfortable, low heeled shoes.
• Avoid weight lifting in poor postures.
• Sleep on the side to reduce ay curve in the spine.
Always sleep on a firm surface.
• Maintain proper nutrition and diet to reduce and
prevent excessive weight. A diet with sufficient daily
intake of calcium, phosphorus, and vitamin D helps
to promote proper bone growth.
• If one smokes, quit smoking. Smoking reduces blood
flow to the spine and causes the spinal discs to
degenerate.
• Avoid excessive stress. Stress will also contribute to
the pain intensity.
References
• Google images
• A.D.A.M. Medical Encyclopedia (04 June, 2011). Cervical spondylosis.
PubMed Health. Available at:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001472/. Accessed
on: 31 August, 2012.
• Shrotriya, Rajesh (Not Available). Cervical spondylosis. Dr. Rajesh A
Shrotriya's Blog. Available at:
http://drrajeshshrotriya.wordpress.com/cervical-spondylosis/. Accessed
on: 31 August, 2012.
• Cervical spondylosis/degenerative neck disease (Not Available).
MedIndia. Available at:
http://www.medindia.net/patients/patientinfo/cervicalspondylosis_diagn
osis.htm. Accessed on: 31 August, 2012.
• Cervical spondylosis (12 July, 2012). Mayo Clinic. Available at:
http://www.mayoclinic.com/health/cervicalspondylosis/DS00697/DSECTION=tests-and-diagnosis. Accessed on: 31
August, 2012.