Neck Pain in Adults _________________________________________________________________________
The origins of radiating neck pain/sensory disturbance are [7]: • Cervical radiculopathy: Sensory, motor, and reflex abnormalities, with pain/sensory distribution from the affected nerve, weakness/tenderness of muscles innervated by the nerve, and hypoactive deep tendon reflexes of the same muscle. • Radicular pain: Sharp, shooting, burning, or aching pain that radiates along the course of a nerve root— without neurologic abnormalities. Neck, upper trapezoid, or scapula tenderness is common. • Referred pain: Pain radiates into the neck, head, upper trapezoid, scapula, or upper arm, but does not involve spinal nerve roots and is non-neuropathic (sensory, motor, reflex changes). The Self-Report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale can help differentiate neuropathic from nociceptive pain [2; 91; 107]. Neuropathic Components in Neck Pain Chronic non-radiculopathic neck pain may have a neuropathic component without apparent nerve root or spinal cord pathology, reflecting CNS alteration [94]. Assessment of a neuropathic component is performed by the physical exam and the PDQ tool [67; 69; 70; 71]. The cardinal features are spontaneous pain (arising without stimuli), abnormal pain response to normally non-painful stimuli such as light touch or moderate heat/cold (allodynia), and exaggerated response to mildly painful stimuli (hyperalgesia). The spontaneous pain may be paroxysmal (e.g., shooting, stabbing, electric shock-like), dysesthetic (e.g., unpleasant abnormal sensations of touch, for example prickling, pins and needles, or crawling), or abnormal thermal sensations (e.g., burning, ice cold). These signs and symptoms can co-occur with loss of afferent sensation. The PDQ is extensively used worldwide in research and clinical practice to identify neuropathic components in chronic spinal pain. A PDQ score greater than 18 indicates a significant neuropathic pain component, regardless of radiculopathy presence [94]. Provocative Tests in Neck Pain Assessment Some specialist and primary care practice guidelines recommend provocative tests ( Table 3 ). They can be helpful adjuncts to history and physical exam findings in identifying potential neuropathic pain origins. These tests are not diagnostic alone, and clinicians should look for patterns in patient-reported, physical exam, and provocative test findings to rule in or rule out specific painful pathologies [29]. DIAGNOSTIC IMAGING Diagnostic imaging has an essential role in some neck pain presentations. However, imaging findings of bulging disks or degenerative changes are common in asymptomatic persons and increase with age [14; 103]. In some patients, the imaged
abnormality is causing their neck pain. In most patients with acute neck pain, imaging fails to identify a pathologic cause or pathologic findings have uncertain relevance or do not change the course of treatment [29]. Imaging can produce false positive (abnormalities are inert) or false negative (pathology undetected) results. Clinicians should correlate imaging results with history and physical exam findings before deciding its relevance to patient symptoms [102]. Imaging results should be presented with patient education on prevalence, treatment, and prognosis. Patients may intensely want a clear-cut diagnosis of their neck pain. Neglecting this education increases the risk of patient fixation on the imaging abnormality (which may be inert), subsequent pursuit of “cure” for the assumed diagnosis, and with failed expectations, initiation into a chronic cycle that may have been prevented [102; 103]. For these reasons, clinical practice guidelines state that patients with acute cervical spine injury, suspected “red flag” conditions, or suspected radiculopathy (and a few select presentations) should receive initial imaging, with imaging considered in other patients remaining symptomatic three to six weeks later [102; 103]. Diagnostic Imaging Modalities Imaging tests differ in accuracy for various pathologies, and no imaging test alone assures correct diagnosis. Information from patient history and physical exam should correlate with imaging results [103]. The indications in the following sections pertain to patients remaining symptomatic after four to six weeks of conservative therapy or with new onset or progression of neurologic symptoms at any follow-up time. Plain Radiography X-ray images are taken from different anatomic views to identify the following abnormalities [51]: • Anteroposterior: Tumors, osteophytes, fractures • Lateral: Stability, spondylosis (spurring, disk space narrowing) • Odontoid: C1–C2 stability, odontoid process (bony projection of C2, prone to fracture) • Bilateral oblique: Degenerative disk disease, foraminal encroachment by osteophytes • Flexion-extension: Subluxations, cervical spine instability A standard cervical spine x-ray series captures anteroposterior, lateral, and odontoid views [19]. All five views are used to evaluate the intervertebral foramen [41]. Radiographs of the lateral cervical spine may show straightening or reversal of the normal lordotic curve, which can represent spasm, guarding, or splinting of muscles that stabilize the neck [41].
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