_________________________________________________________________________ Neck Pain in Adults
rollover motor vehicle accident, ejection from a motor vehicle, accident involving motorized recreational vehicles or horse riding, or bicycle collision [110]. The Canadian C-spine Rule assesses high, low, or no patient risk of cervical spine injury ( Table 4 ). Importantly, neck movement is unsafe to assess in high-risk patients [108; 110]. Cervical spine x-rays are indicated for all high-risk and low-risk patients [19; 108; 110]. CT and/or MRI is recommended for patients with one or more high risk factors, or one or more low-risk factors and inability to rotate neck 45° left and right. The Congress of Neurological Surgeons recommends CT and MRI for cervical spinal injury in patients with cervical spondylitis, even after minor trauma [111; 112]. No-risk patients do not need imaging. Other indications for cervical spine MRI include [103; 110]: • Suspicion of cord compression • Neurologic signs or symptoms, even if x-ray is negative • Ligament or disk injuries suggested by x-ray, CT or clinical findings • Suspected nerve root compression, disk herniation or cord contusion following neck injury • Assessment of red-flag conditions LABORATORY TESTING Unless red flag conditions are suspected, laboratory tests are seldom needed in the evaluation of neck pain [103].
TREATMENT OF NECK PAIN Practice guidelines for primary care are consistent in recommended management of acute neck pain [7; 102; 103]. After red flag causes and radiculopathy are ruled out, the neck pain condition is given a nonspecific diagnosis. Patients should then be instructed to take over-the-counter analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) if needed and to avoid bed rest and maintain activity. Patients should also be reassured their neck pain is benign, time-limited, and has an excellent prognosis. If pain worsens at any time, clinicians should consider specialist referral. If pain persists three to six weeks later, a brief psychosocial assessment is performed to assess “yellow flags,” and patients are referred to physical therapy. This standard guidance has merits of simplicity for clinicians, the benefits of remaining active, and the spontaneous resolution of acute neck pain in some patients. However, some assumptions may be inaccurate, such as the benign, self-limiting nature of most neck pain and patient access to, or availability of, specialist pain providers. Several systemic barriers interfere with patient access to pain therapy, including [113; 114]: • The acute nationwide shortage of pain specialist physicians • The limited availability in some areas of trained physical, psychological, or occupational therapy providers • Insurance non-coverage of nonpharmacologic pain therapies, restrictive coverage that fragments and delays therapy continuity, and/or deductibles that are unaffordable
ASSESSMENT OF RISK LEVEL FOR CERVICAL SPINE INJURY
High Risk One or more of the following factors: • Dangerous mechanism of injury • Age 65 years or older • Paresthesia in upper or lower limbs Low Risk Patients unable to rotate their neck 45° left and right and one or more of the following factors: • Involved in a minor rear-end motor vehicle accident • Comfortable in a sitting position
• Ambulatory at any time since the injury • No midline cervical spine tenderness • Delayed onset of neck pain No Risk Patient has one low-risk factor and can rotate his/her neck 45° left and right. Source: [110]
Table 4
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