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Neck pain

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Neck pain

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Cervicalgia or Neck pain is very common

Most mobile part of spine , supports the weight of head Complex structure- bone disc , joint , muscle and ligament interact to provide stability and motion 7 cervical vertebrae
○ C1 and C2 atlas and axis ( no IV disc between them )
○ C3-7 connected superiorly and inferiorly to IV discs and articulate with adjacent vertebrae through 
 Uncovertebral jts ( joints of Lushka )
 Zygopophyseal joints ( Z joints or facet joints) Facet joints are diarthroses ie have synovium and hence can get involved in systemic inflammatory processes
Often sites of OA changes , osteophyte formation

Affects 15.1 % of the US general population every 3 months and ranks
fourth in global disability ( after back pain , depression and other MSK disorders High prevalence in developed countries Women affected more than men- highest prevalence in middle age Can be recurrent and vary in disability Significant socioeconomic impact Few clinical trials dedicated solely to neck pain ie not well studied Most patients have ” non-specific ” ( simple ) neck pain where symptoms have a postural or mechanical basis

Significant trauma or skeletal injury Symptom suggestive of compression of the spinal cord ( myelopathy ) Symptoms that suggest cancer , infection or inflammation New symptoms before age of 20 or after 55 Intractable or increasing pain H/O osteoporosis H/O rheumatoid arthritis ( atlanto-axial disruption ) Neurological findings ( radiculopathy ) Dizziness drop attacks , blackouts H/O cancer Ripping tearing neck sensation

Cervical spondylosis-Degenerative changes start in the IV discs with osteophyte formation and involvement of adjacent tissue structures Changes in XR common in people over 30- changes weakly correlated with pain Most people do not need further investigations C spine XR may show ” loss of normal cervical lordosis ” suggesting muscle spasm Interpret scans with care as normal people may show imp pathological abnormalities on scanning ( MRI ) Complications of cervical spondylosis include myelopathy or radiculopathy Treatment is conservative Optimal treatment in uncomplicated neck pain – not established yet

Cervical radiculopathy-Constellation of symptoms caused by dysfunction of 1 or more cervical spinal nerve roots Usually due to compression or injury to a nerve root May manifest as pain , motor dysfunction , sensory deficits or alteration in tendon reflexes in the distribution of a specific nerve root Pain may approximate dermatomal distribution- usually unilateral but may be bilateral
Sig dermatomal overlap usual Levels C5-T1 most commonly affected XR has no value in diagnosis of radiculopathy Most patients improve ( result of study from CR due to herniated disc ) within 6 months ie prognosis is usually good Refer for MRI if present + 4-6 weeks or more OR there are objective neurological signs

Cervical myopathy-Results from disease ( eg myelitis ) or injury ( eg trauma or syrinx ) affecting the spinal cord which causes UMN signs UMN signs in a distribution below the level of compression Trauma common cause in young and spondylosis in later life Most commonest cause is a combination of a congenitally narrow spinal canal and progressive cervical spondylosis Course highly variable – periods of dormancy and stepwise progression Although considered an indication for surgery -studies comparing surgical and non-surgical interventions have been mixed Suspect amylotrophic lateral sclerosis if fasciculations and bulbar signs present

Whiplash injury-Described as an acceleration-deceleration mechanism of energy transfer to the neck Often from rear or side impact RTA Attributed to facet jts in about 50 % people Pain often referred to the trapezius , shoulder , mid back and to a lesser extent face Up to 80 % start experiencing neck pain within 1 day and about 50 % continue to suffer an year after the initial injury Late whiplash syndrome – variety of symptoms that persist for > 6 mts after an acute injury . May include
○ neck pain and stiffness
○ persistent headache
○ dizziness
○ upper limb paraesthesia
○ psychological and emotional symptoms

Lack of evidence – in treatment of non-specific neck pain Physiotherapy ( evidence generally favorable or neutral ) Exercise , Posture Encourage to be active and avoid neck immobilisation Try and exclude red and yellow flags Reassess psychological factors Non-opioid based analgesia first line Tricyclic antidepressants Consider topical NSAIDs Muscle relaxant in acute non-radicular pain Intra-articular injections sometimes used to treat cervical fact jt pain- but high technical failure rate and no evidence of benefit

References
 Cervical spondylosis and neck pain BMJ 2007 ; 334 :527-31 The anatomy and pathophysiology of neck pain Nikolai Bogduk , MD , PhD Phys <ed Rehabi Clin N Am 14 ( 2003 ) 455-472 Non-specific neck pain : diagnosis and treatment KCE reports 119 C Cervical Discogenic Pain Syndrome E-medicine July 2014 Neck pain – Whiplash injury CKS NHS April 2015 Neck pain Cervical radiculopathy CKS NHS April 2015 Advances in the diagnosis and management of neck pain Steven P Cohen et al BMJ 2017 ; 358 :j 3221 Physiotherapy Interventions for the Management of Neck and / or Back Pain : A review of Clinical and Cost Effectiveness Canadian Agency for Drugs and Technologies in Health – Rapid Review 2017 ( Abstract ) An approach to neck pain for the family physician AFP Rheumatology Nov 2013 Volume 42 , No 11 Identifying and Treating the Causes of Neck Pain Ginger Evans , MD Med Clin N Am 98 ( 2014 ) 645-661 Neck pain : management in primary care Krysia Dzeidzic et al Arthritis Reasearch UK Reports on the Rheumatic Disease Series 6 Spring 2011 Hands on No 8 Rheumatology in Practice J A Pereira et al Springer Verlaq

 

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