32 COMMON NECK PROBLEMS

TRANSCRIBER: K TAN

SOURCE: BRADDOM 6th Edition

OUTLINE → spine thinks pain is from the limbs instead of the cervical
I. Introduction areas
II. Neuroanatomy of Cervical Spine • Pain from cervical zygapophysiseal joint. See figure 32.30
III. Common Clinical Disorders below
a. Cervical Strain and Sprains o C1-,2 C2-3, C3-4 and C4-5 zygapophyseal joint can refer
b. Cervical Radiculopathy and Radicular Pain symptoms to the head
c. Cervical Joint Pain o C3-4, C4-5 and C5-6 can refer pain to face
d. Cervical Internal Disk Disruption o Ipsilateral or bilateral but NOT contralate
e. Cervical Myelopathy & Myeloradiculopathy
f. Cervicogenic headaches
g. Whiplash Syndrome

INTRODUCTION
Cervical axial pain
• pain in inferior occiput to superior interscapular region,
localizing to the midline or paramidline
Cervical radicular pain
• involves the shoulder girdle and/or distal areas
• typically manifests as pain in the upper limb
•
NEUROANATOMY OF CERVICAL SPINE
• Atlantooccipital (C0-1) – 10 deg flexion, 25 deg extension
• Atlantoaxial (C1-2) – 45 deg of rotation to left or right
• C2-C3 – lateral flexion with coupled with rotation in same
direction
• C3-C4 and C4-C5 – greatest lateral vending
• C4-C5 and C6-C6 – greatest amount of flexion
• Anterior spinal artery – supplies blood to cervical spinal cord
• Intervertebral foramina are widest at C2-C3, decreases
caudally
• Intervertebral disc are thicker anteriorly → cervical lordosis
• Epidural fat is thinner than lumbar area
• Neural foramina is aligned 45 deg forward hence approach
angle for epidural injections should be 70deg instead of
50deg • Cervical intervertebral disk disruption → pain in bilateral
• Vertebral artery passes through transverse foramina paramidline of the upper neck WITHOUT headaches
• Blood supply • Radicular pain
o Radiculomedullar arteries-supplies blood to spinal cord, if o C4-C5 – periscapular or trapezial pain greater than neck
penetrated, can induce cord infarction o C5 – arm
o Radiculopial → Pial network and posterior spinal arteries o C6, C7, C8 – until the arm
o Upper cervical spinal cord supplied by anterior spinal artery o C7 or C8 – middle to lower aspect of ipsilateral scapula
from vertebral arteries o Herniated cervical intervertebral disk – most common
o Midcervical spinal → 2-3 anterior radiculomedullary cause of cervical radiculopathy
arteries o Mechanisms of pain for cervical radiculopathy
o Lower cervical and upper thoracic → anterior ▪ Nerve
radiculomedullary artery from deep cervical artery ▪ Direct root inflammation
• Pain generators ▪ Increased discharge of DRG
o Intervertebral disk ▪ Mechano or chemosensitivity of nerve root
o Zygapophysieal joint ▪ pressure
o Posterior longitudinal ligament o Other causes: trauma, sarcoidosis, arteritis, athetoid or
o Muscles dystonic CP
• Somatic pain • Cervical disk injury – derangement of internal architecture of
o pain produced without irritation of the neural tissue nucleus pulposus and/or annular fibers with little or external
o mesodermal structure (muscle, ligament, joint capsule, deformation
intervertebral disk or periosteum) is stimulated leading to o Circumferential outer annular tears fig 32.14 → radial tears
pain in another mesodermal tissue of the same origin → decreases water imbibing ability of nucleus pulposus →
• Convergence – afferents from both cervical spine and distal destroyed mechanical integrity→ decreased disc space
upper limb converge on 2nd order neurons within spinal cord

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32 COMMON NECK PROBLEMS
o Massage → sedation, reduction of adhesions, muscle
relxation
o Superficial and deep heat → analgesia, muscle relaxation
o ES
o Soft cervical collar → restrict to the first 72 hours post
injury
o Gradual return to activities by 2-4 weeks

CERVICAL RADICULOPATHY AND RADICULAR PAIN

• Pathologic process involving neurophysiologic dysfunction of
the nerve root
• Radicular pain- hyperexcitable state of affected nerve root
• Cervical radiculopathy – reflex and strength deficits
marking a hypofunctional nerve root
• Peak incidence occurs 50-54y/o
• In order of decreasing frequency: C7>C6>C8>C6
• Pathophysiology:
o MC due to cervical intervertebral disk herniation
o 2nd MC spondylitic changes
o Disk herniation fig 32.13 • History
o Dull ache or sharp, lancing pain
C5, C6, C7 Medial scapular edge
C5 or C6 Superior trapezius
Precordium
Deltoid and lateral arm
C6 or C7 Anterolateral forearm
C7 or C8 Posterior forearm
C7, C8 or T1 Posteromedial arm
C6-8 or T1 Upper extremity digits
o Exacerbating factors are those that increase subarachnoid
pressure:
▪ Coughing
COMMON CLINICAL DISORDERS ▪ Sneezing
CERVICAL STRAIN AND SPRAINS ▪ Valsalva maneuvers
• Most commonly caused by motor vehicular accidents ▪ Cervical stenosis if severe
• PE
o MMT more specific than sensory/reflex
o Spurling’s, Lhermitte, abduction relief test, root tension

• Imaging/Diagnostics
• Diagnosis:
o Sharp/dull headaches that localizes to the shoulder girdle
o Aggravated by passive/active motion
o Decreased ROM – due to muscle guarding and splinting
o Tender
o MC involved areas: trapezius and SCM
• Treatment:
o NSAIDs and paracetamol
o Muscle relaxants – but not always for 5-7 days
o Tizanidine or TCAs antidepressant
o Xray: APL, open mouth, flexion and extension
o CT myelography- gold standard for degenerative cervical
spine conditions
o MRI – modality of choice in investigating cervical
radiculopathy
o EMG- nerve function, prognosis
▪ Abnormalities in 2 or more muscles innervated by the
same root but different peripheral nerve
▪ At least 1 corresponding motor and sensory nerve
conduction study of the involved limb
▪ If amplitude of clinically affect limb is >50% of
contralateral limb, then motor recovery will return with
conservative care

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32 COMMON NECK PROBLEMS
• Treatment
o Objectives:
▪ Resolution of pain
▪ Improvement in myotomal weakness
▪ Avoidance of spial cord complication
▪ Prevention of recurrence
o Definitive indication for surgical management: progressive
neurological deficit
o Patient education:
▪ Proper posture, biomechanics, utility of ergonomic
evaluation
o Repetitive and heavy lifting must be avoided
o Modalities
▪ Thermotherapy → increase muscle relaxation
▪ Cold compress 15-30 mins 1-4x/day
▪ Superficial heat 30 mins, 2-3x a day
▪ AVOID deep heating (utz) because increased metabolic
response leads to inflammation → aggravate nerve root
injury
▪ TENS
▪ Cervical orthoses → limits painful ROM
• Soft cervical collars → kinesthetic reminders
o (narrower segment should be positioned anteriorly)
o Worn 1-2 weeks
▪ Cervical traction
• 25 lbs of force 25 mins at an angle of 24 degrees
o Medications:
▪ NSAIDs- 1st line
▪ Muscle relaxants- used for 5-7 days to aid in sleep
▪ TCAs – amitriptyline/nortriptyline 10-25mg ODHS
▪ Antiepileptics –
• gabapentin 300-900mg/day max 3600mg/day
• Pregabalin, tiagabine, zonisamide, oxcarbazepine
▪ Opiates
o Stabilization and functional restoration
▪ Starts with establishing a pain-free interval of cervical
ROM then adding
▪ See table 32.1
o Diagnostic selective nerve root block (SNRB)
▪ Fluoroscopic guided diagnostics SNRB
▪ Sensitivity 100%, specificity 87-100%
o Therapeutic selective Nerve root injection (SNRI)
▪ Corticosteroids
▪ Whiplash induced cervical radicular pain are treated with
2-4 SNRI
o Percutaneous diskectomy/ disc compression
▪ Nucleoplasty – uses coblation energy to vaporize nuclear
tissue into gaseous elementary molecules
▪ Greatest level of pain reduction occurs within the first 2
weeks
▪ Can be combined with SNRI
o Surgery
▪ Indications: intractable pain, severe myotomal deficits
(progressive or stable), myelopathy
▪ Difference between conservative and surgery equalizes
in 1 year
CERVICAL JOINT PAIN
• MC symptomatic level: C2-3 > C5-6 > C6-7
• Usually only 1 joint is symptomatic, rarely 2
• Cervical zygopophyseal joints are a common source of
chronic posttraumatic neck pain.
• Associated with headache
• Pxs with Whiplash injury who complain of posterior
headaches usually have C2-3 zygapophyseal joint pain
• If traumatically induced lower cervical → C5-6
• History and PE
Braddom Chapter 32: Common Neck Problems
o Ask for neck position at the time of impact
o Traumatic C2-C3. Joint pain→ unilateral occipital
headaches
o unilateral paramidline neck pain w/ or w/o periscapular
symptoms and is more painful than associated headaches
o px can pinpoint a localized spot of maximal pain
o assess neurologic function and cervical ROM
o tenderness posterolaterally over a joint
o focal suboccipital pain that occurs or is exacerbated with
45 degrees of cervical flexion and sequential axial rotation
suggests a painful C1–2 joint.
• Imaging
o Xrays
o CT scans – better delineate joint fracture
• Treatment
o Medications
▪ NSAIDs
▪ Opiates
o Physical modalities
▪ Cryotherapy is preferred over superficial heat→ 20
mins 3-4x a day
o Soft tissue mobilization and massage
o Soft cervical collars up to 72 hours after injury
o Restorative phase encompasses stabilization and
functional restoration (ROM, soft tissue length,
strengthening)
▪ Transition begins when there is reduction of pain from
acute injury
o Interventional spine care
o Diagnostic zygapophyseal joint blocks
▪ Definitive means to which to target symptomatic joint
o Therapeutic Zygapophyseal joint injections
o Percutaneous Radiofrequency ablation medial branch
neurotomy
▪ Indication: index neck pain is alleviated by 2 different
medial branch blocks with local comparative anesthetic
▪ Median time to return of pain 9 months
CERVICAL INTERNAL DISK DISRUPTION
• History/PE
o Can present with:
▪ Posterior neck, occipital, suboccipital, upper trapezial,
inter and periscapular pain that is non radiating to the
arm
▪ Vertigo, tinnitus, ocular dysfunction, dysphagia, facial
pain and anterior chest wall pain
o Usually with a history of trauma
o Symptoms can be sudden, gradual or explosive
o Main symptom: axial pain associated with nondescript
upper limb symptoms, exacerbated by prolonged sitting,
coughing and sneezing or lifting, relieved by lying supine
• Imaging studies
o Xrays – hyperostosis and disk space collapse
o MRI – decreased intradiscal signal, but not useful in
detecting symptomatic cervical disks
o Provocation diskography = functional diagnostic testing to
diagnose painful disk level
• Treatment
o NSAIDs – check kidney function 6 weeks after initiating
NSAIDs then after 12 months
o TCAs can be adjunct
o Opioids- short time
o Superficial Heat modalities and TENs
o Traction – but be cautious
o Cervical collars but only within 72 hours post injury then
discontinue
o Cervical spine stabilization, stretching and strengthening
o Interventional spine:
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32 COMMON NECK PROBLEMS
▪ Provocation diskography
• Heavily relies on patient input
• Only test wherein common painful disk is symptomatic
and is typically used when CIDD is in question
• Used for presurgical evaluation
• Healthy disks accept a finite volume of contrast
• Only positive if an asymptomatic control accompanies a
painful disk injection.
▪ Transforaminal Epidural Steroid Injection (TFESI)
• C7 – pain at base of cervical spine
• C5 or C6 – upper neck pain
• Steroid effect is defined as 50% reduction in
preinjection pain lasting for 2 days within 7 days after
the procedure
• If steroid effect does not work after 2 injections, then
cervical diskography or diagnostic zygapophyseal joint
blocks are pursued
• More effective if the symptom duration is more acute
▪ Surgery
• If 2 TFESI does not work then do diskography
• If 1-2 contiguous levels produce pain → surgery
• Only treatment is FUSION
CERIVAL MYELOPATHY AND MYELORADICULOPATHY
• Cervical spondylitic myelopathy – most common cervical
cord lesion AFTER middle age but less common than
radiculopathy
• Average onset is AFTER 50, M>F
• History
o Insidious onset
o CC: cervical axial pain
o Numbness and paresthesia in distal limbs
o Weakness lower>upper limbs, and intrinsic hand muscle
wasting
o Course: initial deterioration then static period that can last
several years
o Bladder symptoms
o If with radicular symptoms, it’s called cervical spondylitic
myeloradiculopathy
• PE
o Weakness LE>UE
o Intrinsic hand muscle weakness
o Pain and temp disturbances - spinothalamic
o Proprioception and vibratory deficits – posterior column
o UMN signs (Babinski, hoffman)
• Imaging studies
o Radiographic show cervical cord compression – most are
spondylitic in nature
o Xrays
o central canal diameter less than 10mm supports
myelopathy
o to diagnose: ~1/3 of the canal must be compromised
o MRI – myelomalacia
▪ Preop transverse area of spinal cord at the site of
maximal compression correlates with clinical outcome
▪ Post op transverse are – clinical recovery
o EMG-NCV
▪ Somatosensory evoked potentials – used to detect
sublinical cord involvement with CC of cervical axial or
radicular pain
Braddom Chapter 32: Common Neck Problems
• Treatment
o Non operative- PT, cervical orthoses
o Surgery
▪ If <3 levels are stenotic → anterior corpectomy and
fusion
▪ If >3 levels with lordosis preserved, laminoplasty is
preferred
▪ If >3 levels with lordosis LOSS, laminectomy and
posterior fusion
CERVICOGENIC HEADACHES
• F>M are affected
• Convergence theory
• C2-C3 zygapophyseal joint → primarily implicated
• History
o Hx of trauma?
o Unilateral and stemming from the posterior occipital region
o Refers toward vertex of scalp, ipsilateral anterolateral
temple, forehead, midface or ipsilateral shoulder girdle
o Can involve the contralateral side
o Deep ache to sharp and stabbing
o Initially intermittent then progresses to persistent
o Usually non throbbing in character
o Autonomic complaints are less apparent than migraines
but can still occur
• PE
o Reduced ROM due to muscle guarding, arthritic changes
or soft tissue inflexibility.
o Localize pain with one finger
o Axial rotation or cervical extension can aggravate
o Spurlings maneuver does not reproduce upper limb
radicular symptoms but usually aggravates axial pain
o Pain reproducible by deep palpation over the involved joint
• Imaging
o Radiographs
o CT scan – if suspicious of fracture
o MRI – intervertebral disks for desiccation, decreased disk
heigh and frank herniation.
o Functional diagnostic tests and treatment
▪ Assess C3-C4 if ok then C1-2 -→ C2-3
WHIPLASH SYNDROME
• PASSIVE Hyperflexion-hyperextension
• 3 components
o Whiplash event
o Whiplash Injury – impairment/injured structure resulting from
whiplash injury
o Whiplash syndrome – set of symptoms arising from injury
• Rear end collisions represent the most common pattern of
whiplash related injury
• Can present with neck pain, headache, shoulder girdle pain,
upper limb paresthesias and weakness
• Can also present with dizziness, visual disturbances and
tinnitus
• Recovery within first 2-3 months after the injury, after 2 years
→ symptom free
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32 COMMON NECK PROBLEMS

END OF TRANS

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