Question 1. What headache red flag is present in this patient’s history? 2. What conditions might explain this client’s symptoms? Discussion The red flag item in this client’s case is the sudden onset of headache in a client over 50 years of age. A workup by her doctor revealed an elevated erythrocyte sedimentation rate (ESR), which is an indication of inflammation. Temporal arteritis is common in clients with polymyalgic rheumatica. This patient did not have tenderness with palpation of the temporal artery but, given her medical history, the doctor ordered a biopsy, which revealed necrotizing arteritis. She was started on prednisone and her headache was gone within two days.
Case Study: Jane Taylor A 64-year-old-woman presents with a four-week history of daily right frontotemporal headaches that she describes as aching and throbbing of moderate intensity. Prior to this recent onset, she had only very occasional mild headaches. Past medical history is significant for hypothyroidism, hyperlipidemia, polymyalgia rheumatica, and degenerative disc disease at C5–C6. She does have intermittent, mild chronic posterior neck pain that she manages effectively with rest and ice. Cervical range of motion was slightly limited but within functional limits with right side bend and rotation equal to left. Neurological exam was normal.
CERVICAL SPINE DIFFERENTIAL DIAGNOSIS
Introduction Neck pain is common, with estimates of 30%–50% of adults experiencing it in any given year (McCartney et al., 2018). It is considered multifactorial in nature, with many systemic and musculoskeletal causes (Kazeminasab et al., 2022). Neck pain has a tendency to becoming chronic, so accurate diagnosis and intervention at early onset is critical. According to Raney et al. (2009), over one-third of patients with neck pain will develop chronic symptoms lasting over six months. Neck/shoulder pain and neck/upper back pain often occur together, making differential diagnosis more difficult (Cavallaro Goodman et al., 2018). Healthcare consideration: The fact that neck pain has a tendency toward chronicity makes differential diagnosis and effective treatment of acute neck pain important. Chronic neck pain increases disability, with accompanying lower quality of life and loss of productivity (Hoy, 2014). It also causes an increase in economic burden. Physical therapists can help decrease the chronicity of acute neck conditions by diligently attending to the presence of red and yellow flags and expertly honing their differential diagnosis knowledge and skills. Traumatic and degenerative conditions of the spine are the major primary causes of neck pain (Cavallaro Goodman et al., 2018). This includes whiplash syndrome and arthritis. A history of falls, motor vehicle crashes, or domestic violence should be explored. Referred pain to the arm may be a cause of local biomechanical dysfunction such as disc disease, but systemic origins of referred pain are also possible (e.g., infection or pulmonary disorders). Rheumatoid arthritis often affects the cervical spine and causes several significant problems (Heick et al., 2023). Red flags for neck pain The presence of red flags in the cervical spine can alert the evaluating clinician to the possibility of significant underlying pathology. Teichtahl et al. (2015) have identified the following neck pain red flags: ● Significant trauma. This includes motor vehicle crashes, falls from a significant height, and some types of sports injuries. However, in older adults even a relatively simple fall can result in injury to the neck. These types of injuries can cause fractures and/or ligamentous disruption. ● History of rheumatoid arthritis . Rheumatoid arthritis is a chronic inflammatory disease that often affects the cervical spine. According to Gillick et al. (2015), rheumatoid arthritis can affect the cervical spine via atlantoaxial instability, cranial settling, or subaxial subluxation (Gillick et al., 2015).
Effective management of cervical issues begins with effective diagnosis. Systemic and viscerogenic sources of pain must be eliminated and musculoskeletal or neuromuscular origins confirmed. A serious underlying cause of neck pain should always be considered and is more likely in people presenting with new symptoms before age 20 years or after age 55 years, weakness involving more than one myotome, or loss of sensation involving more than one dermatome (McCartney et al., 2018). Self-Assessment Quiz Question #23 What percentage of neck pain patients tend to develop chronic symptoms? a. 5%.
b. 10%. c. 25%. d. 33%.
Evidence-based practice: Age of onset of musculoskeletal symptoms can help the evaluating clinician determine thesource and severity of a patient’s condition. For neck pain, new onset neck pain before age 20 or after age 55 can beassociated with a serious underlying cause, especially when accompanied by weakness involving more than one myotome orloss of sensation involving more than one dermatome (McCartney et al., 2018).
● Infective symptoms, including fever, meningism, history of immunosuppression, or intravenous drug use . These findings may indicate the presence of conditions such as epidural abscess or discitis. ● Neurological symptoms such as upper motor neuron signs . Upper motor neuron signs can indicate the presence of cervical cord compression. In addition, neurological signs may indicate a demyelinating process. ● A ripping or tearing sensation in the neck . Arterial dissection, either of the carotid or vertebral artery, can create these symptoms. ● Concurrent chest pain, shortness of breath, and diaphoresis . These symptoms can indicate cardiac involvement, such as myocardial ischemia.
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