What are Red flag symptoms of neck pain?
A serious underlying cause is more likely in people presenting with:
New symptoms before the age of 20 years or after the age of 55 years.
Weakness involving more than one myotome or loss of sensation involving more than one dermatome.
Intractable or increasing pain.
Red flags suggesting possible malignancy, infection or inflammation:
Fever.
Unexplained loss of weight.
History of inflammatory arthritis.
History of malignancy, drug misuse, tuberculosis, AIDS, or other infection.
Immunosuppression.
Pain that is increasing, unremitting and/or disturbs sleep.
Lymphadenopathy.
Exquisite localised tenderness over a vertebral body.
Red flags suggesting myelopathy (compression of the spinal cord):
Insidious progression.
Gait disturbance; clumsy or weak hands; loss of sexual/bladder/bowel function.
Lhermitte’s sign (flexing the neck causes electric shock-like sensations that extend down the spine and shoot into the limbs).
Upper motor neurone signs in the lower limbs (Babinski’s sign - up-going plantar reflex, hyperreflexia, clonus, spasticity).
Lower motor neurone signs in the upper limbs (atrophy, hyporeflexia).
Variable sensory changes (loss of vibration and joint position sense more evident in the hands than in the feet).
Red flags suggesting severe trauma/skeletal injury:
History of trauma.
Previous neck surgery.
Osteoporosis or risk factors for osteoporosis.
Increasing and/or unremitting pain.
Red flags suggesting vascular insufficiency:
Dizziness and blackouts (restriction of vertebral artery) on movement, especially on extension of the neck with upward gaze.
Dizziness, drop attacks.
What are your differentials?
Main Diagnosis = Nerve Root compression or radiculopathy (C5 nerve root),Brachial plexus injury,Focal neuropathy along the course of nerve(injury)
Other differentials = Stroke (lacunar), MS,mypoathy
What are the causes of nerve root compression?
cAUSES-trauma,herniated disc,cervical spondylosis,infection malgnancy,bracheal plexus pathology
What investigations would you do?
Bedside-observation,Peak floe,blood glucose(depending on presentation)
Blood-FBC(infection),U&E’s(CK-myopthies)LFT(malnourished).Bone profile(bone malignancies,ESR & CRP,B 12 and folate
Imaging- X-ray-trauma,MRI,emg,Nerve conduction studies
What is your management?
Management
- Ifred flags(suggesting a serious spinal abnormality) are present,refer urgently or arrange immediate assessment, depending on clinical judgement. If the person has severe or progressive motor weakness, or severe or progressive sensory loss, seek immediate specialist advice.
- Ifcervical radiculopathyhas been present for less than 4–6weeks and there are no objective neurological signs, provide conservative management:
- Provide reassurance and information — the long-term prognosis of people with radiculopathy is good and most cases improve without surgery.
- Encourage activity (includinghome exercise) and a return to a normal lifestyle (including work) as soon as possible.
- However, advise the person not to drive if the range of motion of the neck is restricted.
- Discourage the use of cervical collars because this restricts mobility and may prolong symptoms.
- Advise that a firm pillow may provide comfort at night. It should provide lateral support and support the hollow of the neck and the position should be comfortable. Using two pillows may force the head into an unnatural position.
- Offer oral analgesics(for example, ibuprofen, paracetamol or codeine)— thechoice depends on the severity of pain, personal preferences, tolerability, and risk of adverse effects.
- For prescribing information on nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and codeine, see the CKStopic onAnalgesia - mild-to-moderate pain.
- Consider offeringamitriptyline, duloxetine, pregabalin or gabapentin. For more information, see the CKStopic onNeuropathic pain - drug treatment.
- Consider prescribing muscle relaxants. For information on prescribing diazepam, see the CKS topic onBack pain - low (without radiculopathy).
- Consider a referral forphysiotherapy —this may include strengthening andstretching exercises, andmanual therapy.
- If cervical radiculopathyhas been present for 4–6 weeks or more,orthere are objective neurological signs:
- Refer to confirm the diagnosis with magnetic resonance imaging (MRI), and to consider invasive procedures, such as interlaminar cervical epidural injections, transforaminal injections, or spinal surgery.
- Indications for surgery include signs and symptoms of cervical radiculopathy, andcervical radiculopathy with unremitting radicular pain despite 6 to 12 weeks of conservative treatments, or progressive motor weakness, and MRI that shows nerve root compression.
Management of a Brachial plexus injury?
Types
Erb-Duchenne paralysis
damage to C5,6 roots
winged scapula
may be caused by a breech presentation
Klumpke’s paralysis
damage to T1
loss of intrinsic hand muscles
due to traction
There are two prototypical brachial plexus injuries: damage to the upper roots (known as Erb’s palsy) and damage to the lower roots (known as Klumpke’s palsy.
Causes
Common causes of both include trauma, and axillary radiotherapy (often for breast cancer).
Erb’s palsy
Involves the C5-6 nerve roots with corresponding dermatomal sensory loss, and the so-called “waiter’s tip” sign with shoulder adduction, elbow extension, forearm pronation and wrist flexion. It is most typically associated with shoulder dystocia and traumatic childbirth.
Klumpke’s palsy
Involves the C8-T1 nerve roots with corresponding dermatomal sensory loss, and weakness of the intrinsic muscles of the hand. Uncommonly, T1 involvement may also result in an ipsilateral Horner’s syndrome.
Who would you refer this patient to?
Neurosurgery-if needed
What are the dermatomes and action responsible?
notion
What neurological features can be seen in C5 nerve root compression
notion
Brachial plexus nerves and muscles
notion
Origin Anterior rami of C5 to T1
Sections of the plexus
Roots, trunks, divisions, cords, branches
Mnemonic:Real Teenagers Drink Cold Beer
Roots
Located in the posterior triangle
Pass between scalenus anterior and medius
Trunks
Located posterior to middle third of clavicle
Upper and middle trunks related superiorly to the subclavian artery
Lower trunk passes over 1st rib posterior to the subclavian artery
Divisions Apex of axilla
Cords Related to axillary artery
How can radiculopathy be differentiated from spine cord compression
Patho,
Acute treatment
signs
What is the Prognosis of radiculopathy?
- The prognosis for cervical radiculopathy is favourable: symptoms resolve in most people and without surgical treatment.[6]
- Surgery also has good results but is indicated in only a minority. It is likely that the attitude of the patient to active rehabilitation is very important for a good result. However, the general prognosis for neck pain is not good and it is often chronic and persistent.
What are the Complications of radiculopathy
- If an intervertebral disc compresses the spinal cord, it can produce myelopathy with weakness, hyperreflexia and neurogenic bowel and bladder dysfunction. There may be associated significant upper limb weakness or numbness as well as pain.
- Beware of missing serious underlying disease, including malignancy, infections producing abscesses and inflammatory conditions. Always be alert tored flag
What are UMN and LMN signs?
LMD dysfunction in the limbs manifests as weakness, atrophy, fasciculations and hyporeflexia. The thighs are often a site of marked fasciculation. Fasciculation can be difficult to distinguish from arterial pulsation, so consider if there is an underlying arterial course before defining twitching movements as fasciculation.
- Upper motor neurone signs include:
- Weakness.
- Spasticity.
- Hyperreflexia.
- Positive Babinski’s sign (up-going plantars).
- Clonus.
- Positive Hoffman’s reflex (flicking a finger causes adjacent fingers to flex).
What are the yellow flag signs of chronic pain?
Identify those at risk of a poor outcome. Yellow flags are indicators suggesting increased risk of progression to long-term distress, disability and pain (red flags are clinical indicators of possible serious underlying conditions).
Biomedical yellow flags: severe pain or increased disability at presentation, previous significant pain episodes, multiple site pain, non-organic signs, iatrogenic factors.
Psychological yellow flags: belief that pain indicates harm, an expectation that passive rather than active treatments are most helpful, fear avoidance behaviour, catastrophic thinking, poor problem-solving ability, passive coping strategies, atypical health beliefs, psychosomatic perceptions, high levels of distress.
Social yellow flags: low expectation of return to work, lack of confidence in performing work activities, heavier work, low levels of control over rate of work, poor work relationships, social dysfunction, medico-legal issues.
What are the chronic pain syndromes
Chronic pain is common, you will encounter patients experiencing chronic pain during your careers, no matter which specialty you pursue. Studies have estimated the prevalence of chronic pain in UK adults at anywhere between 13-50%. You may know someone yourself who is living with the daily disease burden of chronic pain.
Chronic pain is more prevalent in some demographic groups, due to a combination of biological, psychological and social factors:
- Older age groups
- Co-morbid disease: particularly depression and cardiovascular disease
- Female gender
- Socio-economic deprivation
- Smokers
- Alcohol dependence
- Increased BMI
Fibromyalgia,Chronic fatigue syndromes,complex regional pain syndrome
Check MLE
How can power be assessEd?Grading
assess ADL, examination against resistance
MRC grading
How can chronic pain be managed?
Almost all pain conditions should be managed with a multifactorial approach. Patient and clinicians can easily fall into the cycle of depending on medications alone and gradually up-titrating doses, leading to increased side effects and possible drug dependence. It is important to remember that medication is just “one slice of the pie” in managing a chronic pain condition. Patients should be supported to adopt active coping strategies and take on responsibility to engage with physiotherapy, self-education and CBT as indicated.
nOTION
Non-pharmacological pain management can be divided into psychological interventions and physical:
When considering how psychological interventions work, we need to think back to the concept of total pain. Psychological therapies work by reducing the anxiety, worry and depression that are often caused by or attributed to the experience of pain. They also address ways in which the person thinks about, and manages their pain to help them to learn to live with their pain.
This is an important concept. When dealing with chronic pain we need to be careful not to falsely reassure or enable the patient to believe that analgesia alone will entirely remove their pain. In reality a significant number of people are living with chronic pain and will continue to do so for their entire life. Psychological therapies such as CBT help people to learn how to manage their pain and re-address their ideas and expectations.
When we look at the treatment of pain with medications, there are a wide variety that work in numerous ways. Similarly with the psychological therapies, not all treatments will work for each person. Careful assessment of the pain, and person, will allow you to select the most appropriate option and work from there.
Some people find graded exercise to be very beneficial, others less so. This is a topic currently undergoing significant debate. There is evidence however to show that cognitive behavioural therapy reduces pain intensity, improves function and reduces negative appraisal or “catastrophizing” (Morley, Stephen and Eccleston (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavioural therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 80. 1-13.) Acceptance and commitment therapy is another kind of therapy that may be suitable for the management of chronic primary pain and is recommended by NICE.
How does a TENS machine work? - Pain gate theory
- The idea that if you apply pressure (“rub it better”) then pain will be reduced -
- C fibres transmit pain from the periphery. C fibres are unmyelinated, A-delta fibres are only minimally myelinated. This makes them comparatively slow.
- The projection neurone/ pain gate transmits signals to the sensory cortex
- A-beta fibers transmit mechanical stimulation impulses (myelinated - comparatively fast)
- Mechanical stimulation activates the inhibitory neurone which is able to inhibit the projection neurone to limit pain.
Summary: mechanicalstimulation inhibits pain signalling
TENs (transcutaneous electrical nerve stimulation) machines are used to manage both acute and chronic pain. They work via sticky pads on the skin that give small electrical currents, feeling like a ‘buzz’ or ‘tingling sensation’. This acts to interrupting painful signals, thus the intensity of the pain is reduced.
They are used for acute pain, such as labour pain. There is little evidence to support their use for chronic pain but some patients may choose to try them, particularly for focal pain such as chronic back paThe WHO pain ladder was initially developed to manage cancer pain and has an emphasis on oral treatments. It is a reliable and safe way to manage pain, but also has flaws in that it was created with oncology patients in mind and leaves out an ever expanding raft of medication and interventions that can be used to treat pain
.
Renal WHO Pain ladder:
Adapted from “Treating Pain in Advanced CKD and Dialysis Patients”, Coalition for Supportive Care for KidneyPatients.
Neuropathic Pain Medication:
Other options used in specialist pain clinics:
- Local anaesthetic. Often used in nerve blocks or epidurals by anaesthetists with a special interest in pain management
- Ketamine
- Clonidine
- NSAIDs
- Capsaicin cream (specialist use). The capsaicin (extracted from chillies) cream is rubbed into the painful area and causes interference with the pain signals, in a similar way to TENS machines. Can be used in neuropathic pain management.
- Facet joint injections for OA spine
- Spinal cord stimulators. Inserted under the skin and deliver small electrical signals to interrupt pain signals. Below is a spinal x-ray of a patient with a spinal cord stimulator in situ (Chronic Primary Pain Management:
There is no evidence for the use of opioids, anti-epileptics, benzodiazepines, cannabinoids or NSAIDs in chronic primary pain and these may even cause harm.
Some of the harmful effects of chronic opioid use include:
- Sedation
- Dizziness
- Nausea and vomiting
- Constipation
- Respiratory depression. Can also increase airway resistance and decrease the patency of the upper airways.
- Physical dependence and tolerance
- Delayed gastric emptying
- Opioid-induced Hyperalgesia
- Immune suppression
- Hormonal suppression
- Muscle rigidity
- Myoclonus
All patients on long-term opioids should have regular laxatives and a small supply of anti-emetics.
Patches can be used to manage stable, chronic nociceptive pain but are unsuitable for acute or acutely changing pain. They are unsuitable for chronic primary pain, as are all opioids.
Opioid use has also be shown in some studies to be associated with poor self-related quality of life and employment status, increased healthcare use and worse pain (Faculty of Pain Medication).
Important Practice Points Regarding Opioids (Faculty of Pain Management).
- Patients who do not achieve useful pain relief from opioids within 2-4 weeks are unlikely to gain benefit in the long term.
- Short-term efficacy does not guarantee long-term efficacy
- Data regarding improvement in quality of life with long-term opioids use are inconclusive
- There is no good evidence of dose-response with opioids, beyond doses used in clinical trials (up to 120mg morphine per day). There is no evidence for efficacy of high dose opioids in long term pain.
Pharmacological Management of Chronic Primary Pain:
- NICE recommends the use of one of the following antidepressants: duloxetine, fluoxetine, paroxetine, citalopram, sertraline or amitriptyline, for people aged 16 years and over to manage chronic primary pain, after a full discussion of the benefits and risks.
- They have been shown to improve pain, quality of life and psychological distress when compared to placebo drugs.
How can strokes be classified and what is a lacunar stroke?
The Oxford Stroke Classification (also known as the Bamford Classification) classifies strokes based on the initial symptoms. A summary is as follows:
The following criteria should be assessed:
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present
Partial anterior circulation infarcts (PACI, c. 25%)
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present
Lacunar infarcts (LACI, c. 25%)
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Posterior circulation infarcts (POCI, c. 25%) involves vertebrobasilar arteries presents with 1 of the following: 1. cerebellar or brainstem syndromes 2. loss of consciousness 3. isolated homonymous hemianopia
Lateral medullary syndrome (posterior inferior cerebellar artery)
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
Weber’s syndrome
ipsilateral III palsy
contralateral weakness
How does cervical spondylosis present?
Definition
Cervical spondylosis describes an osteo-degenerative disease of the cervical spine. It is a common, and underdiagnosed, cause of falls in the elderly.
Epidemiology
Prevalence rises with age for men and women and is the highest in the age group between 50-59 years.
Clinical features
Manifestations include:
Neck pain
Radiculopathy due to compression of nerve roots at the site of foraminal exit
Myelopathy, probably due to dynamic stretch of the spinal cord over impinging spinal osteophytes.
On examination, neck pain is accompanied by flaccid upper limb paresis (due to radiculopathy), variable sensory changes (sometimes including the Lhermitte phenomenon), and spastic paraparesis (with variable involvement of the upper limbs depending on the site of the lesion, and degree of radiculopathy).
Bladder and bowel disturbance is rare.
How is cervical spondylosis managed and what are complications
Oxford?
What is degenerative cervical myelopathy?
Degenerative cervical myelopathy (DCM) has a number of risk factors, which include smoking due to its effects on the intervertebral discs, genetics and occupation - those exposing patients to high axial loading [1].
The presentation of DCM is very variable. Early symptoms are often subtle and can vary in severity day to day, making the disease difficult to detect initially. However as a progressive condition, worsening, deteriorating or new symptoms should be a warning sign.
DCM symptoms can include any combination of [1]:
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
The most common symptoms at presentation of DCM are unknown, but in one series 50% of patients were initially incorrectly diagnosed and sometimes treated for carpal tunnel syndrome [2].
An MRI of the cervical spine is the gold standard test where cervical myelopathy is suspected. It may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change.
All patients with degenerative cervical myelopathy should be urgently referred for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery). This is due to the importance of early treatment. The timing of surgery is important, as any existing spinal cord damage can be permanent. Early treatment (within 6 months of diagnosis) offers the best chance of a full recovery but at present, most patients are presenting too late. In one study, patients averaged over 5 appointments before diagnosis, representing >2 years.
Currently, decompressive surgery is the only effective treatment. It has been shown to prevent disease progression. Close observation is an option for mild stable disease, but anything progressive or more severe requires surgery to prevent further deterioration. Physiotherapy should only be initiated by specialist services, as manipulation can cause more spinal cord damage.
What are the causes of spinal cord compression?How does it present?
Definition
Spinal cord compression (SCC) results from processes that compress or displace arterial, venous, and cerebrospinal fluid spaces, as well as the cord itself.
Clinical features
Cord compression typically presents with acute (or less commonly subacute) upper motor neuron signs and sensory disturbance below the level of the lesion.
Deep and localised back pain is often also present, along with a stabbing radicular sensory disturbance at the level of the lesion. Bladder and bowel involvement is also commonly seen.
Causes
Trauma
Neoplasia (seen in 5-10% of cancer patients, presenting complaint in 20% of these)
Infection (especially TB in at-risk patients)
Disc prolapse
Epidural haematoma
How can spinal cord compression be managed?
Management
Patient with clinical features suggestive of spinal cord compression or cauda equina syndrome should have an urgent WHOLE spine MRI, with an aim (in appropriate cases) to surgically decompress within 48 hours.
In patients where malignancy is demonstrated on MRI, or in patients where clinical suspicion is high, administration of dexamethasone 16 mg daily in divided doses (with PPI cover) is indicated.
