NECK &

UPPER
BACK
DIFFERENTIAL DIAGNOSIS
SCREENING
PMHx
• Cancer
• Diabetes
• Immunosuppression
• Rheumatologic disorders
• Tuberculosis
• Infection (any recent)
• Motor vehicle accident
• Blunt impact
• Repetitive injury
• Sudden stress caused by lifting or pulling or trauma of any kind
 VISCEROGENIC CAUSES OF NECK PAIN (CERVICAL)
CANCER Metastatic lesions (leukemia, Hodgkin’s disease); Cervical bone
tumors; Cervical cord tumors; Lung cancer - Pancoast’s tumor;
Esophageal tumor; Thyroid cancer
CARDIOVASCULAR Angina; Myocardial infarction; Aortic aneurysm; Occipital migraine;
Cervical artery ischemia or dissection; Arteritis
PULMONARY Lung cancer - Pancoast’s tumor; Tracheobronchial irritation; Chronic
bronchitis; Pneumothorax; Pleuritis involving the diaphragm
GASTROINTESTINAL Esophagitis; Esophageal cancer
INFECTION Vertebral osteomyelitis; Meningitis; Lyme disease; Retropharyngeal
abscess; epidural abscess (post-steroid injection)
OTHERS Osteoporosis; Fibromyalgia; Psychogenic (non-organic causes);
Fracture;
Rheumatoid: Rheumatoid arthritis and atlantoaxial subluxation;
Psoriatic arthritis; Polymyalgia rheumatica; Ankylosing spondylitis;
Viral myalgias
Cervical lymphadenitis
Thyroid disease
Risk Factors for Assessment
• Depends on pt’s family hx, and disease, illness, or present condition
• Medications
• Physical and sexual abuse
• Age
• Routine screening for:
Osteoporosis
Hypertension
Incontinence
Cancer
Vestibular or balance problems
Other potential problems
CLINICAL PRESENTATIONS/ SIGNS AND SYMPTOMS
• Systems review
• Assessment of pain and symptoms
Characteristic of pain:
Onset
Description
Duration
Pattern
Aggravating and relieving factors
Associated signs and symptoms
• Effect of position
• Night Pain
MOST COMMON RED FLAGS ASSOCIATED WITH BACK PAIN OF SYSTEMIC ORIGIN

• Age less than 20 or over 50 (malignancy)/over 70 (fracture)

• Previous history of cancer
• Constitutional symptoms (e.g., fever, chills, unexplained weight loss)
• Failure to improve with conservative care (usually over 4 to 6 weeks)
• Recent urinary tract infection, blood in urine (or stools), difficulty with urination
• History of injection drug use
• Immunocompromised condition (e.g., prolonged use of corticosteroids, transplant recipient,
autoimmune diseases)
• Pain is not relieved by rest or recumbency
• Severe, constant nighttime pain
• Progressive neurologic deficit; saddle anesthesia; urinary or fecal incontinence
• Back pain accompanied by abdominal, pelvic, or hip pain
• History of falls or trauma (screen for fracture, osteoporosis, domestic violence, alcohol use)
• Significant morning stiffness with limitation in all spinal movements (ankylosing spondylitis or
other inflammatory disorder)
• Skin rash (inflammatory disorder [e.g., Crohn’s disease, ankylosing spondylitis])
 CAUSES OF BACK PAIN IN CHILDREN
INFLAMMATORY Diskitis (most common before age 6); Vertebral osteomyelitis; Spinal
CONDITIONS abscess; Nonspinal infections (e.g., pancreatitis, pyelonephritis);
Rheumatoid arthritis (cervical spine involved most often); Reiter’s
syndrome; Psoriatic arthritis; Ankylosing spondylitis (presents during
adolescence); Inflammatory bowel disease

DEVELOPMENTAL Spondylolysis; Spondylolisthesis; Scheuermann’s syndrome; Scoliosis

CONDITIONS (especially left thoracic)
TRAUMA Muscle strain; Vertebral stress or compression fracture; Overuse
syndrome; Physical abuse
NEOPLASTIC Leukemia; Hodgkin’s disease; Non-Hodgkin’s lymphoma; Ewing’s
DISEASE sarcoma (primary); Osteogenic sarcoma (osteosarcoma) [primary];
Rhabdomyosarcoma (rare; skeletal metastasis)
OTHER Mechanical (hip and pelvic anomalies, upper cervical spine
instability); Herniated disk; Psychosomatic (conversion reaction);
Benign tumors (osteoid osteoma); After lumbar puncture; Juvenile
osteoporosis
REVIEW OF SYSTEMS
Musculoskeletal System
Whiplash Injury
• aka Acceleration flexion-extension neck injury
• sudden neck acceleration-deceleration accidents leading to injury of ligaments, joints,
muscles and nerves.

Clinical Presentation
• Neck tightness and stiffness
• Occipital headache
• Shoulder, arm, and back pain
• Numbness in the arms
• Tinnitus
• TMJ pain
• Dysphagia (retropharyngeal hematoma)
• Decreased range of motion of the neck
• Depressive symptoms

IMAGING STUDIES
• Plain cervical spine films (anteroposterior, lateral, and odontoid views)
• Flexion/extension x-rays
• CT scan to exclude fracture
• MRI as alternative or in addition to CT in selected cases
Torticollis
• aka Twisted neck, “Wry neck”, Congenital
deformity of SCM muscle, Spasmodic torticollis
• contracture of the muscles of the neck
that causes the head to be tilted to one side

Etiology: Unknown
• some thought to as a result of a defect of the
brain’s basal ganglia to process neurotransmitters
• Infection, specifically pharyngitis, tonsillitis,
retropharyngeal abscess
CLINICAL PRESENTATION 2. Head often tilted toward the
affected side
• Congenital muscular torticollis
• Findings in other cases
1. Mass in the SCM shortly after depend on etiology
birth
2. Mass gradually subsides,
leaving a shortened, contracted IMAGING STUDIES
SCM muscle • Plain radiographs in cases of
3. Head tilted toward affected & trauma or to rule out
rotated in the opposite direction congenital abnormalities
4. Facial asymmetry and other • MRI
secondary changes persisting • Electrodiagnostic studies
into adulthood
• Spasmodic torticollis
1. “Spasms” in the cervical
musculature; may be bilateral
and uncontrollable
Cervical Osteoarthritis
• Aka cervical spondylosis
• normal wear-and-tear of aging; degeneration
of discs and other cartilage, spurs or abnormal
growths called osteophytes may form on
the bones in the neck
• Levels commonly affected C5-C6, C6-C7
• 60% of >45y/o; 85% of >65y/o
CLINICAL PRESENTATION
• Neck pain & stiffness; pain increases on extension and decreases on
flexion
• tingling, numbness and weakness in shoulder or arms

IMAGING STUDIES
• Neck X-ray
• CT Scan
• MRI
Nervous System
 Cervical Myelopathy and Radiculopathy
Cervical compression of Hand numbness, Ext, rot and lat flex Arm positions Sensation
Myelopathy the spinal cord in head & neck may all cause pain have no effect on affected, abN
the neck pain, hoarseness, pain pattern
vertigo, tinnitus,
deafness

Cervical pinching of the Arm & neck pain Pain increased by Pain may be Dermatome
Radiculopathy nerve roots as in dermatome ext and rot or lat relieved by sensation
they exit the distribution flex putting hand on affected
spinal cord or head (C5, C6)
cross the IV disc
Cervical Wide- Loss of Possible Spastic UE & LE (+) Decreased Atrophy
Myelopathy based hand loss of paresis DTR pathological superficial
gait, function bowel and (especially hyperactive reflex reflex
ataxia; bladder LE, UE
proprioc control affected
eption later)
affected

Cervical Gait not Altered Bowel and Weakness DTR (-) (-) Atrophy
Radiculopathy affected hand bladder in hypoactive pathological superficial (late sign),
function not myotome reflex reflex hard to
affected but not detect
spasticity early
Cardiovascular System
Angina
• May cause chest pain radiating to the
anterior neck and jaw (sometimes appearing
only as neck and/or jaw pain and misdiagnosed
as temporomandibular joint (TMJ) dysfunction.

Myocardial Ischemia
• Reduces the heart muscle's ability to pump
blood. Condition wherein the heart muscle is
not getting enough blood.
Vertebrobasilar Insufficiency
• Occurs when the flow of blood to the back of your
brain is reduced or stops.
• Most common cause: Atherosclerosis

Risk factors:
• Smoking
• HTN
• Diabetes
• Obesity
• >50y/o
• Genetics
• Hyperlipidemia
• Atherosclerosis
• Peripheral arterial disease
Clinical Presentation • loss of balance and coordination
• loss of vision in one or both eyes • difficulty swallowing
• double vision • weakness in part of your body
• dizziness or vertigo
• neck pain Diagnosis
• numbness or tingling in the hands or feet • CT or MRI
• nausea and vomiting • MRA
• slurred speech • Angiogram
• changes in mental status, including
confusion or loss of consciousness
• drop attack — sudden generalized
weakness
Respiratory System
REVIEW OF SYSTEM: RESPIRATORY SYSTEM
• Some conditions known to refer pulmonary pain to the neck/upper back are
tracheobronchial irritation, pneumonia and bronchitis.
• Proper assessment should be done to rule out respiratory diseases.

SCREENING:
PMHx
Red Flag: Recent hx of one of these diseases - pleuritis, pneumothorax, pulmonary
embolism, cor pulmonale, and pleurisy.
CLINICAL PRESENTATION:
• Pulmonary pain patterns based in part on the lobe(s) or segment(s) involved and on
the underlying pathology.
• Pancoast’s tumors of the lung may invade the roots of the brachial plexus causing
entrapment as they enlarge, appearing as pain in the C8 to T1 region, possibly
mimicking thoracic outlet syndrome.
• Tracheobronchial irritation can cause pain to be referred to sites in the neck or anterior
chest at the same levels as the points of irritation in the air passages. 

ASSOCIATED SIGNS & SYMPTOMS:

** Neck or back pain that is reproduced, increased with inspiratory movements, or
accompanied by dyspnea, persistent cough, cyanosis, or hemoptysis must be evaluated
carefully.
Gastrointestinal System
REVIEW & SCREENING OF SYSTEM: GASTROINTESTINAL SYSTEM
• Anterior neck (esophageal) pain may occur usually with a burning sensation
(heartburn) or other symptoms related to eating or swallowing. 
 Severe esophagitis may refer pain to the anterior cervical or more often, the mid-
thoracic spine with pain pattern starting anteriorly and spreading around the chest
wall to the back.
• Anterior neck pain can also occur as a result of a diskogenic lesion.
• As with cervical pain of GI origin, there may be a history of alcoholism with esophageal
varices, cirrhosis, or an underlying eating disorder.
 Clients with eating disorders who repeatedly binge and purge by vomiting may also
report anterior neck pain.
 If liver impairment is an underlying factor, there may be signs such as asterixis
(liver flap or flapping tremor), palmar erythema, spider angiomas, and CTS.
ASSOCIATED SIGNS & SYMPTOMS:
• Sore throat
• Pain that is relieved with antacids, upright position, fluids, or avoidance of
eating
• Pain that is aggravated by eating, bending, or recumbency
Endocrine System
REVIEW OF SYSTEM: ENDOCRINE SYSTEM
• Torticollis of sternocleidomastoid may be a sign of underlying thyroid involvement.
• Anterior neck pain that is worse with swallowing and turning the head from side to
side may be present with thyroiditis. 
• Palpation of a firm, fixed, and immovable soft tissue mass or lump at the anterior
spine while the patient is swallowing may raise a red flag of suspicion for neoplasm.
• Anterior disk bulge into the esophagus or pharynx and/or anterior osteophyte of the
vertebral body may give the sensation of difficulty swallowing or feeling a lump in the
throat when swallowing.
• Anxiety can also cause a sensation of difficulty swallowing with a lump in the throat.
• Conduct a cranial nerve assessment for cranial nerves V and VII.
OTHER SYSTEMS
• Fibromyalgia is characterized by widespread musculoskeletal pain and can
cause pain and stiffness in the neck. 
• Rheumatoid arthritis - a systemic disease often affects the cervical spine
causing atlantoaxial instability.  Cervical spine is often affected early on
(first two years) in the course of disease. 
• Atlantoaxial subluxation may present with sensation of the head falling
forward during neck flexion or a clunking sensation during neck extension
as the AA joint is reduced spontaneously. Symptoms with cervical
radiculopathy are common with AA joint involvement.
Thank you
for
listening!
- Vera & Paula