Tuesday, April 3, 2007

Neck Pain

The following is an informative article from the British Medical Journal on cervical spondylosis which can cause neck and arm pain. For full text, click on the link below.

Cervical Spondylosis and Neck Pain

BMJ 2007;334:527-531 (10 March), doi:10.1136/bmj.39127.608299.80
[Free full-text BMJ article (pdf)] [BMJ abstract]

Clinical Review

Allan I Binder, consultant rheumatologist
Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB.
Correspondence to: allan.binder@nhs.net

Most patients who present with neck pain have "non-specific (simple) neck pain," where symptoms have a postural or mechanical basis. Aetiological factors are poorly understoodw1 and are usually multifactorial, including poor posture, anxiety, depression, neck strain, and sporting or occupational activities.w2 Neck pain after whiplash injury also fits into this category, provided no bony injury or neurological deficit is present.w3 When mechanical factors are prominent, the condition is often referred to as "cervical spondylosis," although the term is often applied to all non-specific neck pain. Mechanical and degenerative factors are more likely to be present in chronic neck pain.

In cervical spondylosis, degenerative changes start in the intervertebral discs with osteophyte formation and involvement of adjacent soft tissue structures. Many people over 30 show similar abnormalities on plain radiographs of the cervical spine, however, so the boundary between normal ageing and disease is difficult to define.w4 Even severe degenerative changes are often asymptomatic, but can lead to neck pain, stiffness, or neurological complications.

I will concentrate on the diagnosis of cervical spondylosis and the evidence available for the different treatments. I will also mention some practical measures that are thought to be important but have not yet been studied. Specific conditions like fibromyalgia, disc prolapse, and whiplash will not be considered, although some patients with these conditions may have been included in therapeutic studies.

Summary points

--The diagnosis of cervical spondylosis is usually based on clinical symptoms.
--Patients need detailed neurological assessment of upper and lower limbs as cervical degeneration is often asymptomatic, but can lead to pain, myelopathy, or radiculopathy.
--"Red flag" symptoms identify the small number of patients who need magnetic resonance imaging, blood tests, and other investigations.
--The best treatments are exercise, manipulation, and mobilisation, or combinations thereof.
--Radiculopathy has a good prognosis and may respond to conservative measures.
--Results of neck surgery for myelopathy or intractable pain are often disappointing.

Box 1 Presenting features of cervical spondylosis

Symptoms

--Cervical pain aggravated by movement.
--Referred pain (occiput, between the shoulder blades, upper limbs).
--Retro-orbital or temporal pain (from C1 to C2).
--Cervical stiffness—reversible or irreversible.
--Vague numbness, tingling, or weakness in upper limbs.
--Dizziness or vertigo.
--Poor balance.
--Rarely, syncope, triggers migraine, "pseudo-angina"w15.

Signs

--Poorly localised tenderness.
--Limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides).
--Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy).

Box 3 "Red flag" features and the conditions they may suggest

Malignancy, infection, or inflammation

--Fever, night sweats.
--Unexpected weight loss.
--History of inflammatory arthritis, malignancy, infection, tuberculosis, HIV infection, drug dependency, or immunosuppression.
--Excruciating pain.
--Intractable night pain.
--Cervical lymphadenopathy.
--Exquisite tenderness over a vertebral body.

Myelopathy

--Gait disturbance or clumsy hands, or both.
--Objective neurological deficit—upper motor neurone signs in the legs and lower motor neurone signs in the arms.
--Sudden onset in a young patient suggests disc prolapse.

Other

--History of severe osteoporosis.
--History of neck surgery.
--Drop attacks, especially when moving the neck, suggest vascular disease.
--Intractable or increasing pain.

[References available in the free full-text pdf version]

© 2007 BMJ Publishing Group Ltd.

The above message comes from "BMJ", who is solely responsible for its content.

No comments: