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Approaching Neck Pain MCP IPA LBP Task Force


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Title: Approaching Neck Pain MCP IPA LBP Task Force

Approaching Neck Pain MCP IPA LBP Task Force
  • 2009-10

MCPIPA Spinal Pain Task ForceCommittee Members
Neck Pain
  • Doug Speedie MD Ellen Mead PT
  • John Gustavson PhD KC Lewis MD
  • Mike Dohm MD Britt Smith PT
  • Ellen Price DO Todd Hegstrom MD Cindy Holst
  • Consulted Susan Hemley MD, Mike Reeder DO

Disclosure Statement
  • Dr. D.K. Speedie is a full time employee of Rocky
    Mountain HMC
  • He is not on any outside Speakers Bureau
  • However, given that he had two kids in college
    AGAIN, he is willing to entertain any offer
  • The information in this presentation has been
    evaluated by the Committee for accuracy
  • Speedie, however has not

Spinal Pain Task Force Mission
  • To create Evidence Based Clinical Pathways that
    promotes the effective, efficient and quality
    care of neck low back pain patients
  • To recognize those individuals with Red Flag

Spinal Pain Task Force Mission
  • To recognize those individuals with non-specific
    neck pain or low back pain and treat them
    according to evidence based guidelines
  • To appropriately treat other forms of neck pain
    and low back pain according to evidence-based
    guidelines, where available.
  • Finally, to improve care which is likely to
    reduce overall health costs to the community

(No Transcript)
Neck Pain Definitions
  • Several distinct types and the evaluation and
    treatment is often different. Types include
  • Neck Pain with Headache
  • Neck Pain with Radiculopathy
  • Neck Pain with Myelopathy
  • Neck Pain
  • Mechanical Neck Disorder
  • Whiplash-Associated Disorders
  • Vertebral-Basilar Dissection

Neck Pain Prevalence
  • 12 Month Prevalence of 30-50
  • Lifetime Prevalence of 70
  • Point Prevalence of 22
  • Estimated Incidence of 213 per 1000 per years
  • Accounts for 25 of chiropractic visits, 15 of
    PT visits, 2 to family physicians, and 70 of
    musculoskeletal disease seen by rheumatologists
    relates to neck pain

Neck Anatomy
  • The cervical spine consists of seven vertebrae
    denoted as C1 through C7. The bony anatomy of the
    atlas (C1) and axis (C2) are unique, whereas C3
    through C7 have fairly consistent anatomy

Neck Anatomy
  • The atlas is a ring, consisting of anterior and
    posterior arches with two lateral masses and
  • no vertebral body.

Neck Anatomy
  • The lateral masses articulate with the skull
    through the occipital condyles and form the
    atlanto-occipital joints supported further by
    occipital membranes.
  • The atlanto-occipital joint is responsible for
    approximately 50 of total flexion and extension
    in the neck

Neck Anatomy
  • The axis consists of two lamina, a spinous
    process, two lateral masses, two pedicles, a
    vertebral body, and the dens or odontoid peg

Neck Anatomy
  • There is no intervertebral disk between the
    atlanto-occipital joint and atlantoaxial joint
  • Without the stability conferred by a disk, the
    area is often involved by destructive
    inflammatory arthritides, which may result in
  • The axis articulates with the vertebra above and
    below through the superior and inferior facets

Neck Anatomy
  • Posteriorly, the axis has a large spinous
    process, which can be easily palpated just below
    the occiput.
  • The atlantoaxial articulation also provides
    approximately 50 of rotatory motion of the
    cervical motion.

Neck Anatomy
  • C3 through C7 vertebrae all have fairly similar
  • Each vertebra consists of a body, two
    interconnecting pedicles, two lateral masses, two
    transverse processes, two laminae, and a spinous
  • The transverse and spinous processes project
    outward, providing attachment for ligaments and
    muscles and creating a moment arm to facilitate

Neck Anatomy
Neck Anatomy
  • The spinous processes of C3 through C6 are bifid,
    whereas the C7 spinous process usually is not.
  • The C7 spinous process is large, however, and the
    next most prominent and easily palpable spinous
    process below C2.

Neck Anatomy
  • There are five articulations between each
    vertebra from C2 through C7, including the
    intervertebral disk, two uncovertebral joints,
    and two facet joints.

Neck Anatomy
  • Uncovertebral joints are formed between uncinate
    process above, and uncus below
  • Two lips project upward from the superior surface
    of the vertebral body below, and one projects
    downward from the inferior surface of vertebral
    body above
  • This is not a synovial joint.

Uncovertebral joints
Cervical Nerves
  • The first cervical nerve emerges from the
    vertebral canal between the occipital bone and
    the atlas, sometimes called the suboccipital nerve

Cervical Nerves
  • There are eight cervical nerves (C1-C8). All
    nerves except C8 emerge above their corresponding
    vertebrae, while the C8 nerve emerges below the
    C7 vertebra. (In the other portions of the spine,
    the nerve emerges below the vertebra with the
    same name.)

Basic Principles of Neck Pain Management
  • History and physical exam to exclude Red Flag
  • Physical exam for neurologic screening
  • Diagnostic triage into broad categories mentioned
  • Judicious use of diagnostic imaging
  • Use interventions with proven efficacy
  • Non-invasive approaches for most Neck Pain

What are the Red Flags?
  • Fever or Chills
  • Unintentional weight loss
  • History of osteoporosis or cancer with high risk
    of metastasis
  • Increasing neurological deficit
  • I V Drug Use
  • Inflammatory arthritis, RA or Ankylosing
  • Intractable pain

Neck Disorder with Headache (NDH)
  • It has recently been accepted that cervical spine
    structures, particularly those innervated by the
    upper three cervical nerves, have the capacity to
    refer pain into the head and cause neck pain and

Neck Disorder with Headache
  • The possible sources of cervicogenic headache are
    the joints, ligaments, muscles, dura, and
    arteries innervated by the upper three cervical
  • There is no evidence that specific MRI findings
    are associated with neck pain, cervicogenic
    headache, or whiplash exposure

NDH Treatment
  • Multimodal therapy for NDH has the most benefit
    including Mobilization/ Manipulation, Stretching
    exercise and coordination and strengthening
  • Should be done by physical therapists
  • At-home treatment is not of significant benefit.

NDH Treatment
  • Exercise alone, medication, massage, acupuncture
    and orthopedic pillows have some benefit.
  • Botox, home exercise, manipulation alone, static
    traction and have not been shown to be of any
  • Surgery has no place in the treatment of NDH

Neck Pain with Radiculopathy
  • Cervical radiculopathy is characterized by
    dysfunction of a cervical spinal nerve, the roots
    of the nerve, or both.
  • Patients present with pain in the neck and one
    arm, with a possible combination of sensory loss,
    loss of motor function, or reflex changes in the
    affected nerve-root distribution

Neck Pain with Radiculopathy
  • Annual incidence rate of 107.3 per 100,000 for
    men and 63.5 per 100,000 for women,
  • Peak at 50 to 54 years of age.
  • History of physical exertion or trauma preceded
    the onset of symptoms in only 15 percent of

Neck Pain with Radiculopathy
  • Study from Rochester MN-- 26 percent of 561
    patients with cervical radiculopathy underwent
    surgery within three months of the diagnosis
  • Recurrence, (reappearance of symptoms of
    radiculopathy after a symptom-free interval of at
    least 6 months) occurred in 32 percent of
    patients during a median follow-up of 4.9 years.

Neck Pain with Radiculopathy
  • 90 percent of the patients had normal findings or
    were only mildly incapacitated owing to cervical
  • Most common cause (in 70 to 75 percent of cases)
    is foraminal encroachment of the spinal nerve
    including decreased disc height and degenerative
    changes of the uncovertebral joints anteriorly
    and facet joints posteriorly

(No Transcript)
Neck Pain with Radiculopathy
  • In contrast to disorders of the lumbar spine,
    herniation of the disc is responsible for only 20
    to 25 percent of cases
  • Other causes, including tumors of the spine and
    spinal infections, are infrequent.
  • The nerve root that is most frequently affected
    is the C7, followed by the C6.

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Spurlings Maneuver
  • Spurlings Maneuver Spine extended with head
    rotated to affected shoulder while axially loaded
  • Sensitivity 30-50, but specificity 92-95

Neck Pain with Radiculopathy
  • MRI is the imaging approach of choice
  • No clear guidelines as to when imaging is
  • Reasonable indications include the presence of
    symptoms or signs of myelopathy, significant
    neurologic loss, or
  • Red flags suggestive of tumor or infection, or
    the presence of progressive neurologic deficits
  • It is appropriate to limit the use of MRI to
    those who remain symptomatic after four to six
    weeks of nonsurgical treatment

Neck Pain with Radiculopathy
  • As with Low Back Pain, there is a high frequency
    of abnormalities detected on MRI in asymptomatic
  • Disk herniation or bulging (57 percent of cases)
  • Spinal cord impingement (26 percent)
  • Cord compression (7 percent)
  • Carette, NEJM, 2005

Radiculopathy Treatment
  • Multimodal therapy including Mobilization,
    Manipulation, Stretching exercise and
    Coordination and Strengthening exercise
  • Epidural Steroids Injections (ESI)
  • Medication, acupuncture and orthopedic pillows
    have some benefit
  • Traction has little benefit

  • ASIPP states that the level of evidence for
    cervical intralaminar epidural steroid injections
    is level II-1 (controlled trials w/o
    randomization) and the recommendation for its use
    is 1C strong.
  • The Bone and Joint Task Force agrees that there
    is evidence supporting short-term symptomatic
    improvement of radicular symptoms in patient's
    when treatment involves a short course of
    epidural or selective root injections with

Radiculopathy Treatment -Surgery
  • It is not clear that long-term outcomes are
    improved with surgical treatment of cervical
    radiculopathy compared to non-operative measures
  • However, relatively rapid and substantial pain
    and impairment relief after surgical treatment
    seems to be reliably achieved.

Radiculopathy Treatment - Surgery
  • Most surgeries for disc disease in the neck are
    accompanied by fusion as removing the disc in the
    neck typically results in native fusion.
  • Fusion results in adjacent joint arthritis and
    further limits ROM
  • Results from cervical disc arthroplasty for
    radicular symptoms seem to show outcomes similar
    to discectomy and fusion but long-term viability
    has not been demonstrated

Radiculopathy Treatment - Surgery
  • The PRESTIGE Cervical Disc is a metal-on-metal
    design (stainless steel).
  • Concern with the artificial cervical discs is
    that they may have to be in place 40 years and
    the longest studies to date are at 2 years.
    Ongoing studies are taking place out to 7 years.
    RMHP does not cover

Prodisc -C
  • More difficult revision with keeled device
  • Persistent or recurrent neural compression
    because osteophytes do not resorb as they do with
  • Sagittal splitting vertebral fracture

Neck Pain with Myelopathy
  • Dysfunction of the spinal cord is termed
    myelopathy.  The usual sources of this
    dysfunction include cervical stenosis from
    osteoarthritis and herniated discs
  • Occasionally, an acute disc can herniate
    centrally and cause a myelopathy. If left
    untreated, the effects can be irreversible.

Neck Pain with Myelopathy
Cervical Spondylotic Myelopathy
  • Cervical spondylotic (osteoarthritic) myelopathy
    (CSM) is the most common spinal cord disorder in
    persons more than 55 years of age
  • There are three important pathophysiologic
    factors in the development of CSM (1) Static
    mechanical Static mechanical factors result in
    the reduction of spinal canal diameter and spinal
    cord compression. (2) Dynamic mechanical and (3)
    Spinal cord ischemia

Cervical Spondylotic Myelopathy
  • Static mechanical disc hardening and
    degeneration, osteophytic spurring and the
    ligamentum flavum may stiffen and buckle into the
    spinal canal
  • Dynamic Mechanical Factors with flexion, the
    spinal cord lengthens, thus stretching over
    ventral osteophytic ridges.

Cervical Spondylotic Myelopathy
  • Dynamic Mechanical Factors During extension, the
    ligamentum flavum may buckle into the spinal cord
    causing a reduction of available space for the
    spinal cord
  • Spinal cord ischemia probably plays a role in
    the development of CSM, particularly in later
  • Other associated factors include heavy labor,
    posture and genetic predisposition

Cervical Spondylotic Myelopathy
Cervical Spondylotic Myelopathy (CSM) Symptoms
  • In the early stages of CSM, complaints of neck
    stiffness are common because of the presence of
    advanced cervical spondylosis
  • Other symptoms include crepitus in the neck with
  • Stabbing pain in the arm, elbow, wrist or
    fingers or a dull "achy" feeling in the arm and
    numbness or tingling in the hands.

Cervical Spondylotic Myelopathy Symptoms
  • The hallmark symptom of CSM is weakness or
    stiffness in the legs
  • Symptoms may be asymmetric particularly in the
  • Unsteadiness of gait
  • Weakness or clumsiness of the hands
  • Slight hesitancy on urination

Cervical Spondylotic Myelopathy Signs
  • Atrophy of the hand musculature
  • Hyperreflexia
  • Lhermitte's sign (electric shock-like sensation
    down the center of the back following flexion of
    the neck)
  • Sensory loss particularly proprioception or
    vibratory in the extremities may be asymmetrical
  • Gait abnormalities
  • Hoffman and Babinski reflexes should also be

Hoffmans sign
  • The test involves tapping the nail or flicking
    the terminal phalanx of the third or fourth
    finger. A positive response is seen with flexion
    of the terminal phalanx of the thumb
  • Often considered the upper limb equivalent of the
    Babinski's sign

Neck Pain with MyelopathyDiagnostic Testing
  • MRI of the cervical spine is the procedure of
    choice during the initial screening process of
    patients with suspected myelopathy.
  • Electrical testing is rarely useful in most
    patients with myelopathy however, it may help in
    the exclusion of specific syndromes such as
    peripheral neuropathy

Cervical Spondylotic MyelopathyNatural History
  • Evaluating the efficacy of any particular
    treatment strategy for CSM is difficult
  • As many as 18 percent of patients with CSM will
    improve spontaneously
  • 40 percent will stabilize
  • Approximately 40 percent will deteriorate if no
    treatment is given.
  • No way to predict

Myelopathy Surgical Indications
  • Multilevel spondylotic myelopathy, as evidenced
    by ANY ONE of the following
  • Clinical symptoms of myelopathy examples
  • Clumsiness of hands
  • Urinary urgency
  • Bowel or bladder incontinence
  • Frequent falls

Myelopathy Surgical Indications
  • Clinical signs of myelopathy examples include
  • Hyperreflexia
  • Hoffmann sign
  • Increased tone or spasticity
  • Loss of thenar or hypothenar eminence
  • Gait abnormality
  • Positive Babinski sign

Mechanical Neck Pain
  • Muscle strain is the most common cause of neck
    pain followed by ligamentous sprain
  • Like the Low Back, these probably account for 85
    of cases presenting in the office
  • Acute muscle-mediated pain can be subdivided into
    delayed onset muscle soreness (DOMS) and muscle
    contusion, which occur after direct tissue

Mechanical Neck Pain
  • Almost everyone will experience DOMS at some time
    in their life.
  • Usually occurs after unusual physical activity.

Mechanical Neck Pain
  • The symptoms usually appear 24 to 48 hours after
    such activity and abate completely within several
  • The mechanism of this type of muscle injury
    consists of excessive eccentric muscular

Mechanical Neck Pain
  • When a direct and forceful compression is applied
    to a muscle, as occurs commonly during sports
    participation, muscle contusion may develop.
  • The trauma produces local tissue necrosis,
    cellular death, extravasation of blood into the
    tissues, and secondary inflammatory response
  • Uncommon cause of neck pain. More typical of

Mechanical Neck Pain
  • Likewise, ligamentous injury not only is limited
    to pathologic elongation (sprain) but also can be
    classified further as a partial or a complete
  • Ligamentous sprains are produced by forceful,
    passive stretching beyond the physiologic range
    or with strong muscular contractions
  • If there are no Red Flags, there is no reason to
    image these people

Mechanical Neck Pain - Treatment
  • None or
  • Multimodal therapy including Mobilization,
    Manipulation, Stretching exercise and
    Coordination and Strengthening exercise
  • Massage, Electrotherapy, Low-level laser therapy,
    Orthotic pillow, Acupuncture all have some
  • Surgery is not indicated

Whiplash Associated Disorder (WAD)
  • Whiplash is defined as an acceleration-deceleratio
    n mechanism of energy transfer to the neck.
  • The current model of injury ? bodys inertial
    response causing the head neck to undergo large
    amounts of displacement without any direct
  • The most recent data from the US suggest that
    this injury costs 29 billion yearly.

Whiplash Associated Disorder (WAD)
  • Rear end impact ? patient's torso is rapidly
    carried forward.
  • Movement ? development of the S shaped cervical
    curve forcing C-spine into an abnormal,
    non-physiologic motion of lower extension and
    upper flexion

Whiplash Associated Disorder (WAD)
  • The reverse occurs with a front end impact.
  • Motion has been shown to produce elongation and
    failure strain of the facet capsule and ligaments
    at the C6-7 level during the initial S-shaped
  • May be facet joint spearing of the superior facet
    on the inferior articular facet as well as
    stretching of the anterior ligamentous tissues

Whiplash Associated Disorder (WAD)
  • May be a variety of unique injuries involving the
    spinal dorsal ganglia, and intervertebral disks.
  • Location of the dorsal root ganglia and nerve
    roots and render them vulnerable to excessive
  • There may be hemarthrosis, capsular tears,
    articular cartilage damage, joint fractures and
    capsular rupture.

Whiplash Associated Disorder (WAD)
  • Ligamentous injuries in the mid and lower
    cervical segments may also contribute to
    development of the persistent symptoms.
  • There may be strains in the superficial posterior
    neck muscles.

Whiplash Associated Disorder (WAD)
  • Mechanical tissue injury has been shown to create
    local and systemic inflammation ? profound
    changes in muscle tissue.
  • There are a may also be denervation contributing
    to the muscular degeneration.

Whiplash Associated Disorder (WAD)
  • Most individuals recover within two to 3 weeks
  • A number of individuals with this injury will
    sustain longer problems with the injury.
  • Symptoms of whiplash injury may include pain,
    dizziness, visual and auditory disturbances,
    photophobia, fatigue, cognitive difficulties such
    as concentration and memory loss, anxiety,
    insomnia and depression.

  • The Québec Task Force categorizes WAD into 4
  • WAD I Stiffness or tenderness in the neck no
    physical signs of a injury
  • WAD II Stiffness or tenderness, some physical
    signs of injuries such as point tenderness or
    trouble turning the head
  • WAD III stiffness or tenderness and neurologic
  • WAD IV fracture or dislocation of the neck.
  • The problem with his classification scheme is
    that virtually everyone requiring treatment will
    be a WAD II.

Proposed classification Physical/Psychological Impairment
WAD 0 No complaint about neck pain No physical signs
WAD I Neck pain, complaints of pain/stiffness/tenderness only No physical signs
WAD II A Neck pain Motor Impair ? ROM, Altered Muscle recruitment (CCFT) Sensory Impair Local cervical mechanical hyperalgesia
WAD II B Neck pain Motor Impair ? ROM, Altered Muscle recruitment (CCFT) Sensory Impair Local cervical mechanical hyperalgesia Psych. Impair ? Psychological distress (GHQ-28, TAMPA)
Proposed classification Physical/psychological Impairment
WAD II C Neck pain Motor Impair ? ROM, Altered muscle recruitment ? Cranio-cervical flexion test (CCFT), ? Joint position error (JPE) Sensory Impair Local cervical mechanical hyperalgesia, Generalized sensory hypersensitivity (mechanical, thermal, (BPPT)) Some may show Sympathetic Nervous System (SNS) disturbances Psych. Impair ? Psychological distress (GHQ-28, TAMPA), ? Elevated levels of acute post-traumatic stress ? Impact of Event Scale (IES)
WAD III Motor Impair ? ROM, Altered muscle recruitment (CCFT) ? JPE Sensory Impair Local cervical mechanical hyperalgesia, Generalized sensory hypersensitivity (mechanical, thermal, BPPT) Some may show SNS disturbances Psych. Impair ? psychological distress (GHQ-28, TAMPA), ? Elevated levels of acute post-traumatic stress (IES) Neurological signs of conduction loss ? DTRs, muscle weakness, Sensory deficits
Proposed Classification Physical Psych. Impairments present
WAD IV Fracture or dislocation
Whiplash Associated Disorder (WAD)
  • Significant presenting findings include loss of
    active cervical ROM
  • Measurements of ROM discriminate between patients
    with persistent whiplash associated disorder
    compared to those with no further problems ?
    sensitivity of 86.2, specificity of 95.3.

Whiplash Associated Disorder (WAD)
  • Loss of balance and disturbed neck influenced
    eye-movement control are present in chronic WAD
  • Vestibular control mechanisms utilize neck
    musculature for balance and the mechanisms may be
    damaged by the whiplash injury

Whiplash Associated Disorder (WAD)
  • Whiplash injuries may also present with
    widespread sensory hypersensitivity to a variety
    of stimuli including pressure and thermal.
  • Hypersensitive responses suggest augmented
    central pain processing mechanisms.
  • Cold hyperalgesia in sympathetic nervous system
    changes could also indicate peripheral nerve

Whiplash Associated Disorder (WAD)
  • Initial pain and functional disability levels ?
    useful in the prediction of those at risk for
    transitioning from acute to chronic.
  • High pain and disability levels with physical and
    psychological factors, including early presence
    of ?cervical movement, cold temperature
    hyperalgesia, and PTSD symptoms are all strong
    predictors of poor outcome.

Whiplash Associated Disorder (WAD)
  • There may be significant psychological factors in
    chronic whiplash pain including affective
    disturbances, anxiety, depression, and behavioral
    abnormalities such as fear of movement.
  • Some of the psychological factors and mental
    function abnormalities may be the result of
    traumatic brain injury.

Whiplash Associated Disorder (WAD)
  • Though there is typically no direct blunt force
    trauma to the head, the acceleration
    deceleration portion of the injury may cause a
    coup-contrecoup phenomenon.

Whiplash Associated Disorder (WAD)
  • Without the direct blunt force trauma, TBI may
    not be as readily apparent.
  • Given that these may be severe accidents, there
    may be significant risk of posttraumatic stress
    disorder as well which has been shown to increase
    the risk of chronic WAD

Whiplash Associated Disorder (WAD)
  • Clinical evaluation should aim to identify the
    presence of physical and psychological
  • Measure cervical active range of motion
  • Specific sensory assessments ? no current
    consensus about the most appropriate testing
  • MRI is not useful

Whiplash Associated Disorder (WAD) Treatment
  • Physical rehabilitation
  • Psychological support and possibly
    neuropsychological evaluation
  • Pharmacological pain management
  • Surgical intervention not useful

Vertebral-Basilar Dissection
  • Often presents as strictly neck pain making
    diagnosis challenging, however, if the following
    symptoms occur consider immediate referral.
    Female to male ratio 31, average age 40
  • Dizziness (vertigo) and Disequilibrium
  • Dysesthesia, (facial)
  • Dysphagia
  • Diplopia
  • Dysarthria

  • Algorithm The Committees recommended approach
    to neck pain presenting in the office
  • Template The Committees recommended approach
    to the History and Physical. Can be used in a
    paper chart or the basis of a template for an

Physical Exam
  • Gait abnormality _________________ Palpation
    for spinal tenderness _________
  • Complete with of Normal
  • ROM Flexion_____Extension_____
  • R Rotation_____L Rotation_____

Physical Exam
  • Strength Testing
  • R L
  • Handgrip
  • Finger Abduction
  • Wrist Extension  
  • Biceps
  • Triceps
  • Deltoid
  • Inspection for Atrophy
  • R L 
  • Biceps
  • Triceps
  • Deltoid
  • Hand
  • Forearm

Physical Exam
  • Reflexes
  • Biceps R L Triceps R L
  • Hoffmans
  • Babinskis
  • Spurlings sign

  • Physical Findings Associated with Specific
    Cervical Radiculopathy Reference for the
    specific findings of the various levels that are
    seen with cervical radiculopathy.
  • Dermatome Map Reference for the specific
  • Neck Disability Index Essentially the Oswestry
    for the neck. Useful in assessing for Yellow
    flags as well as following progress in the neck
    pain patient

Approaching Neck Pain MCP IPA LBP Task
ForceThe END
  • 2009-10