Patients can complain of neck pain from a variety of reasons and in this video I am going to try to outline the most common causes of neck pain and how to treat it.
The first thing you want to identify is if the patient has neck pain or shoulder pain. Shoulder pain and neck pain problems overlap. You need to know if the origin of the pain is the cervical spine or if the shoulder itself is the origin of pain.
Does the patient symptoms improved by shoulder abduction and placing the hand over the head, then the pain has the cervical spine origin.
Shoulder abduction test
Lifting the arm above the head usually relieves the symptoms because it decreases tension on the affected nerve.
Is the pain more when you move the shoulder?
Then the shoulder itself is the source of the pain.
An important cause of neck pain is disc herniation. The patient will complain of numbness, paresthesia and radiculopathy, which is shooting pain that radiates from the neck to the arm. The patient will have unilateral arm pain, numbness and tingling in a specific dermatome in the hand. As you see here in this diagram.
There will be weakness in a specific muscle group. And cervical radiculopathy, the pain is sudden and goes to the arm. Radiculopathy occurs due to compression of the nerve root either by a disc herniation or by arthritis that narrows the foreman. Cervical disc herniation occurs most frequently at the level of C6-C7 and it will affect the C7 nerve root. It can also occur at C5-C6 and in this case, it will affect the C6 nerve root.
How to you test for cervical spine disc herniation?
Neurological exam of the patient will include:
Motor testing
Sensory testing
Reflex testing
This is how you test the motor strength of the nerve root from C5-T1. This is how you test the sensory as you see her in this diagram. This is how you test the reflex as you can see in this diagram.
Spurling test for cervical spine radiculopathy
What is the Spurling test?
The Spurling test is considered to be positive with neck extension and rotation towards the painful side reproduces symptoms in the ipsilateral arm. The natural history of cervical radiculopathy is favorable with resolution of the symptoms in most cases. And cervical radiculopathy, the patient will have 70 to 80% successful outcome after 2 to 3 months with conservative treatment.
How do you really treat cervical disc herniation?
We are going to start nonsurgical treatment first. Use anti-inflammatory medication, isometric exercises, physical therapy, and muscle relaxers. Get an MRI if symptoms do not improve after 6 weeks of conservative treatment.
The MRI result should be correlated with the clinical symptoms. False positive rate of the MRI is high. . In asymptomatic patients older than 40 years old, you will find that 57% of these patients will have at least 1 degenerative disc on the MRI. The MRI may show you a problem with the disc in patients you are not complaining of any neck pain. Therefore, use a result of the MRI wisely and do not scare the patient, because what you find on the MRI could be a normal process.
Persistent disabling pain for 6 to 12 weeks despite nonoperative treatment can be an indication for surgery. The surgery is usually anterior and it involves decompression and fusion of the involved disc space. Asked the patient if the patient has gait disturbance (unstable gait when walking, wide-based gait) or hand clumsiness, may indicate cervical myelopathy due to compression of the spinal cord (serious condition). The patient may have decreased manual dexterity and difficulty manipulating fine objects such as buttoning and on buttoning shirts. The patient may have occipital headache and a sense of discomfort in the neck. The patient may not have severe neck pain. In general, and cervical myelopathy the onset of pain is insidious, gradual, poorly characterized, and localized. Cervical myelopathy is a slow progressive process with stepwise progression and deterioration over time. In cervical myelopathy, the MRI will show compression of the spinal cord. Cervical myelopathy you will find upper motor neuron signs including a positive Hoffmann sign. This is how you will see a positive Hoffmann sign.
What are other upper motor neuron signs?
You will find the patient will have hyperreflexia, positive Babinski test and clonus test. Early recognition and early surgery is important for a good outcome. The severity of the symptoms and early treatment is most important to the outcome. Surgery is done for any functional impairment of the gait or the hands. Usually the treatment in this situation is surgery back decompression and fusion.
