Transcript Examination

THE PAINFUL NECK
Definitions
High cervical pain: Neck pains radiating to the
occiput and originating from a derangement of
the cervicooccipital junction (occiput, C1, C2)
Cervicobrachalgia: Neck pains radiating to the
shoulder and possibly to the arm.
Levator scapule syndrome: Cervicoscapular pains
due to contraction of the levator scapulae and
the upper part of the trapezius muscle. It occurs
either on one or on both sides.
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Differential diagnosis
- Pain originating in the shoulders and arms
(painful shoulder)
- Polymyalgia rheumatica (painful shoulder)
- Early stage of rheumatic diseases:
Rheumatoid arthritis:any age
Ankylosing spondylitis: 30 years
- Infections or bone lesions of the cervical spine,
eg, spondylodiscitis, metastases.
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• Anatomo-physiological principles
- Sudden movements or repeatd muscular strains
can provoke cervical pains or torticollis. Very
often such pains are causedby irritation of the
joints and ligaments. The fact that the vertebral
artery and autonomic nerve fibres are very close
proximity to the joints adds a neurovascular
component.
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• Anatomo-physiological principles
- The posterior cervical joints and the lateral joints of
Luschka contain synovial tissue, which can participate in
the inflammation of generalised rheumatic diseases.
Wear and tear on the different structures is often
premature, with loss of disc space and osteoarthrosis of
the posterior cervical joints.Where there are associated
neurological signs, these most frequently take the form
of a radicular syndrome due to irritation of a cervical
nerve root by osteophytesfrom the lateral joints of
Luschka. Cervical are much rarer than lumbar disc
prolapses.
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• Examination
1- Palpation of muscle contracyions and painful
areas: This is best performed with the patient
sitting. There are often several iindurated or
painful areas. If the origin of the pain is found, all
of the patient’s symptoms will be elicited.
2- Active and passive movement of the cervical
spine: The movements initiating the pain
described by the patient should be sought.
Limitation of movements is often asymmetrical.
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• Examination
Flexion and extension of the neck with
measurement of the chin to sternum
distance. Repeated measurements make
it possible to follow the evoution of the
condition
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• Examination
3- Involvement of the cervico-occipital
junction: This is sought by rotation of the
head in the bowed position (head bowed
keeping the neck straight, thus preventing
rotation of the inferior cervical spine).
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• Examination
4- Neurologic examination: In the case of
cervicobrachialgia a neurological
examination should also be performed.
Most painful radiations to the arms are
diffuse, without clear radicular distribution,
and correspond with the irradiations from
joint or ligamentous lesions.
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• Examination
4- Neurologic examination:
- Check for cutaneous sensation.
- Check for reflexes.
- Check for muscle power. In checking
muscle power, compare healthy and
affected sides. False muscle weakness
may be caused by the pain.
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• Examination
4- Neurologic examination:
• Examination of the trapezius (C3,C4; accesory
nerve). The patients is asked to lift the shoulders
whilst resistance is applied from above.
• Examinations of the deltoid (C5,C6). The patient
is asked to lift the arms whilst resistance is
applied from above.
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• Examination
4- Neurologic examination:
• Examination of the biceps (C5,C6): resistance
opposing flexion of the elbow.
• Examination of the extensors of the wrist (C7,
C8): resistance opposig extension of the wrist.
• Examination of the dorsal interosseous muscles
(C8,T1): resistance opposing separaion of the
fingers.
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• Examination
4- Neurologic examination:
If neurological deficits are suspected, the
patient should be referred to a specialist.
The existence of cervical myelopathy
should be kept in mind.
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• Examination
5- Supplementery investigations: The clinical impression
dictates the choice of appropriate laboratory tests.
Lateral and anteroposterior X-rays of the cervical spine
are necessary in all persistent neck pains in order to
exclude major anatomical lesions (spondylodiscitis,
metastases, post-traumaic lesions). In cervicobrachialgia
oblique X-rays show the size of the intervertebral
foramina. Dynamic studies and X-rays of the occiputocervical junction are the domain of the specialist. When
interpreting the X-rays it should be remembered that
degenerative lesions, such as discopathies, are related
to the age of the patients rather than sheddng light on
pathology responsible for his or her symptoms.
Radiographs of asymptomatic patients of the same age
often show just as many degenerative changes. Never
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• High cervical pain
The pains typically radiate to the occiput and
even the temples. The emergence of the
occipital nerves is tender to palpation and the
patients often complains of headache (usually
occipital but occasionally temporal). Pain
reproduced by movement of the high cervical
spine confirms the diagnosis.
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• Neck pains and cervicobrachialgia
Neck adpains present as acute torticollis, repetetive or
even chronic neck pains, or cervicobrachialgia. Most
pains radiating to the arm are diffuse, without any
precise trajectory, and come from ligamentous and
mscular lesions. It is the clinical examination that should
establish whether there is nerve root involvement.
Although the treatment for cervicobrachialgia is
essentially the same as for discrete cervical
radiculopathy, the presence of neurological deficits calls
for consultation with a specialist. The existence of
cervical myelopathy should be kept in mind.
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• Levator scapulae syndrome
Contaction of the neck muscles can be provoked
by dysfunction of the cervical spine, by certain
repetitive movements (e.g.,typewritng in a bad
position), or by psychological tensions. The
muscle contraction is generally the cause of the
pain (strain on the insertions, muscular fatigue),
inducing a vicious cycle from which new
contractures, new pains, fatigue, and increased
nervous tension arise.
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• Levator scapulae syndrome
Clinical examination reveals permanent
contraction of the muscles insertig at the
supramedial angles of the scapulae and at
the superior portion of the cervical spine.
The contractures can be so strong that
indurated and tender nodules become
palpabl.
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Therapeutic guide
Treatment of neck pain and cervicobrachialgias
Aims:
- Suppression of the pain
- Restoration of physiological movement.
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Therapeutic guide
Treatment of neck pain and cervicobrachialgias
In the acute stage
Rest: A soft cervical collar is the best method of
resting the cervical spine. A variety of pillows can
be useful at night. The immobilisation must be
done in the correct positio: it must be painless
and able to be maintained without any effort on
the part of the patient.
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Therapeutic guide
Treatment of neck pain and cervicobrachialgias
In the acute stage
Medications: At the beginning high doses of
analgesic or anti-inflammatory drugs are often
needed, the dosage of which can subsequently
be decreased if the condition runs a favourable
course. Muscle relaxants may be given as well.
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Therapeutic guide
Treatment of neck pain and cervicobrachialgias
In the sub-acute stage
Passive physiotherapy: Most patient find musclerelaxing massages beneficial. Electrotherapy
can be additional help (e.g., short vawes or
ather sources of local heat). The methods of
passive physiotherapy are useful above all in
preparing the patient for active mobilisation.
Passive physiotherapy should not be prolonged
indefinitely in chronic cases.
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Therapeutic guide
Treatment of neck pain and cervicobrachialgias
In the sub-acute stage
Manipulations: Manipulations often reduce the
symptoms of neck pain or cervicobrachialgia.
They should not be commenced until some
mobility has been recovered, at least for certain
movements. A neurological deficite is an
absolute contra-indication to all manipulations.
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Treatment of the levator scapulae syndrome
Aims:
- Reduction of the pain.
- Relaxation of the mucles.
- Prevention of recurrence.
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• Treatment of the levator scapulae syndrome
Means:
- Oral anti-inflammatory medication
- Infiltration by lidocaine and possibly steroids into the
painful indurated areas
- Ulrtasound; pressure massaging of the muscles and
their insertions
- This must be followed by gentle mobilisation of the neck,
shoulders, and arms to restore physiological
movements.
- To prevent recurrence:Eliminate the possible causes of
contractions, such as cervica pain, periarthritis of the
shoulder, or bad working postures.Reduce psychological
tensions which could contribute to th muscle contractions