Neck Pain



Neck Pain


James C. Farmer

David A. Bomback

Thomas P. Sculco






ETIOPATHOGENESIS



  • Degeneration of the intervertebral dise can lead to pain referred to the neck, posterior skull, and/or upper shoulders. This occurs as a natural consequence of the normal aging process with a resulting decrease in the water content of the disc. Disc degeneration can be affected by many external factors including repetitive occupational mechanical strain, and a history of diving or heavy weight lifting. The structures affected within the neck include the intervertebral disc, zygapophyseal joint with associated facet capsules, ligaments, musculature, and the neural elements. Changes can be acute (e.g., traumatic), chronic, or acute on chronic.


  • Acute herniation of the disc material posteriorly may result in impingement of the nerve root and/or spinal cord. The distribution of pain in cervical radiculopathy often fits a dermatomal distribution characteristic for each particular nerve root. When cord compression occurs, the changes within the cord can be caused by acute compression by the disc material, as well as compression of the vascular supply to the cord.


  • Cervical spondylosis involves loss of disc space height. As a result of the degeneration within the disc and the decreased intervertebral height, altered spinal biomechanics ensue, with osteophytes forming along the area of the disc space as well as posteriorly along the facet joints. This can be associated with nerve root and spinal cord compression.


PREVALENCE

Prevalence of neck and referred shoulder/brachial pain has been reported to be 9%. In a series of 205 patients who presented with neck pain and were managed nonoperatively, 79% were noted to be asymptomatic or improved at a minimum follow-up of 10 years. Symptoms of 13% were unchanged, and only 8% had worsening of their symptoms. Radiographically, 25% of patients in their fifth decade have been shown to have degenerative changes in one or more discs. By the seventh decade, this number increases to over 75%.


CLINICAL MANIFESTATIONS


I. NECK PAIN



  • Signs and symptoms. Neck pain is a pain that is perceived by the patient as existing primarily within the axial portion of the spine. Pain may radiate to the base of the skull or to the midupper periscapular region. The pain may involve the posterior trapezius muscles or the posterior deltoids. The pain itself may be limited to a focal area or may involve a more global region. Night pain is common because the neck becomes a weight-bearing area. The longer the pain exists the more difficult it is for patients to localize it. Because the neck can be a prominent area of referred pain from thoracic organs such as the heart or aorta, the physician must be aware of the patient’s comorbid medical issues.


  • Physical examination. Examination of the patient with neck pain should include noting the position in which the neck is held. When there is severe neck spasm, the head may be flexed laterally to that side or even rotated. Muscle spasm can often be visualized and can be palpated posteriorly along the paraspinal musculature. Examination should include inspection of the symmetry of the paraspinal muscles as well as the trapezius and shoulder musculature. Any signs of atrophy must be noted. Strength and range of motion of the shoulder should be tested, as well as examination for focal tenderness within the shoulder (to help rule out the shoulder as a source of potential pain or to define coexistent shoulder disease).


  • Range of neck motion should include flexion, extension, rotation, and lateral bending. Normal flexion demonstrates the ability to touch the chin to the chest. Normal neck extension allows the occiput to approach the prominent C7 spinous process. Rotation is normally 70 degrees bilaterally and lateral bending is
    50 to 60 degrees bilaterally. Palpation for carotid artery pulses as well as for the presence or absence of supraclavicular adenopathy should be performed.


II. CERVICAL RADICULOPATHY

Jul 29, 2016 | Posted by in RHEUMATOLOGY | Comments Off on Neck Pain
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