Fig. 2.1
Surface anatomy of cervical spine
Cervical spine vertebrae differ from lumbosacral vertebrae in several ways. First, there are foramina on each side which allow passage of the vertebral arteries. Additionally, the facet joints in the C-spine have steeper angles which allow for more rotation between vertebrae without subluxation. The most important difference, however, is the nonsynovial joint, known as the uncovertebral joint or “joint of Luschka.” During midlife, this joint prevents a disc rupture from directly pressing onto the nerve root. This means that most disc herniations in the neck occur posteriorly (unlike the LS spine, in which most herniations occur laterally). As we age, these joints can form osteophytes that can impinge upon the nerve root or compress the cervical cord directly causing cervical myelopathy. Figure 2.2 shows the major differences between lumbar and cervical vertebrae.
Fig. 2.2
Comparison of lumbosacral (left) and cervical (right) vertebrae
Red Flags
Some serious conditions can present as neck pain, and the following are considered “red flag” conditions which should spur further evaluation.
1.
Trauma: Neck pain in the setting of trauma should receive emergent evaluation and is best managed in an emergency department. If there is any fear of spine instability, the patient should be immobilized with an appropriate cervical collar and transferred by emergency medical personnel.
2.
History of neck surgery: New neck pain in a patient who has had prior neck surgical intervention must be approached with caution. Strong consideration to immediate referral should be given in all but the most clear-cut cases.
3.
Rapidly progressing neurological deficit: Patients who present with rapid, progressive neurologic deficits should be suspected of having CNS involvement and should be urgently referred.
4.
Neck and/ or jaw pain associated with cardiac risk factors and exertion: Referred pain with cardiac ischemic pattern or associated with diaphoresis should be urgently referred.
Epidemiology of Cervical Spine Pathology
Neck pain is common, occurring half as often as low-back pain; almost 70 % of the population experiences neck pain at some time. Women are affected more than men. Other risk factors are cigarette smoking, advancing age, and certain occupations. The prevalence of neck pain at any given time is 15 %.
The most common post-traumatic cause of neck pain is a whiplash injury, typically following an automobile accident. The mechanism of injury is a hyperextension motion followed by deceleration and may damage anterior muscles, ligaments, and discs. A number of high-quality studies have shown that a certain percentage of patients, on average 33 %, reported chronic symptoms after sustaining this type of injury. The Quebec task force recommends that only patients with peripheral neurological findings and those with fracture dislocation require surgical intervention. These types of injuries often involve litigation and, under our current tort system, encourage expensive imaging, most of which have no proven value in improving the course of clinical improvement.
Patients who work in occupations which involve repetitive use of the upper extremities, such as machine operators, office workers, and carpenters, are also prone to neck pain. These types of disorders often involve nerve entrapment, and nerve conduction studies may be useful to localize the origin of entrapment neuropathies.
A careful history is the most useful tool in differentiating C-spine pathologies. Important questions include the nature, duration, and location of the pain, associated numbness or tingling in either or both upper extremities, other musculoskeletal symptoms, and any history of trauma.
In patients presenting with neck pain, the physical exam must include a neurologic evaluation. The necessary exam will differ depending on patient presentation (evaluation is described in detail below). Most patients with neck pain and an absence of neurologic findings will have benign neck pain and require no further workup. Two different sets of rules have been created to assist healthcare providers in determining when imaging is appropriate (the Canadian Task Force (CTF) X-ray Rules and the Nexus Rules). It has been suggested that the CTF rules are more relevant in the primary care setting. These rules are shown in Table 2.1.
Table 2.1
Canadian C-spine task force rules
Condition 1: perform radiography in patients with any of the following: |
Age 65 years or older |
Dangerous mechanism of injury |
Fall from 3 ft (1 m) or 5 stairs |
Axial load to the head, such as diving accident |
Motor vehicle crash at high speed (>62 mph) |
Motorized recreational vehicle accident |
Ejection from a vehicle |
Bicycle collision with an immovable object |
Paresthesias in the extremities |
Condition 2: in patients with none of the above characteristics, assess for any low-risk factor that allows safe assessment of neck range of motion. Perform radiographs to assess patients WITHOUT any of the low-risk factors listed here. Perform the range of motion examination described in condition 3 to assess patients WITH any of the low-risk factors listed |
Simple rear-end motor vehicle accident |
Sitting position in emergency department |
Ambulatory at anytime |
Delayed onset of neck pain |
Absence of midline cervical spine tenderness |
Condition 3: test active range of motion in patients with ANY of the low-risk factors listed in condition 2. Perform radiography in patients who are unable to actively rotate the neck 45° both left and right. Patients able to rotate their neck, regardless of pain, do not require imaging |
Common Clinical Presentations
Myofascial (Mechanical) Neck Pain
This is by far the most common neck condition the primary care provider will encounter. Mechanical neck pain is typically reported as diffuse and nonspecific and made worse with neck movement. Two-thirds of these patients have pain in their shoulders and upper arms in a nonradicular pain pattern. The other one-third of these patients will present with headaches sometimes radiating to the front of the head. Upon examination, there may be localized “trigger” points in the cervical and peri-scapular musculature. Injection of 2 cc 0.5 % bupivacaine or 1 % lidocaine into the trigger point can be both diagnostic and therapeutic.
The primary goal in evaluation of patients with myofascial neck pain is to exclude worse pathology. In the absence of neurologic symptoms or neurologic findings, these patients can be managed conservatively. Management strategies include use of NSAIDs, activity and postural modification, physical therapy (PT), muscle relaxants, and, occasionally, limited use of opioids.
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