General Medical Officer (GMO) Manual: Clinical Section: Neck Pain

Cervical pain

Cervical pain is nearly as common as low back pain. In the working population between the ages of 25 to 29, nearly 30 percent will have one or more acute attacks of neck pain. Usually it is less disabling than low back pain. Neck pain with radiation to the arm increases with age and has been experienced by nearly one quarter of working men by age 45.

History of present illness (HPI)

The HPI should include the following points:

general health and age.
occupation.
recent or remote injury.
the presence or absence of constitutional symptoms (fever, chills, weight loss, fatigue, and night sweats).
other joint complaints.
specific description of the character and pattern of the pain (radicular, radiating, pain out of proportion, night-time, burning, constant, and activity related).
neurologic associations (weakness, numbness, tingling).

The review of systems must include cardiac, respiratory, rheumatologic, psychological, and gastrointestinal complaints.

Physical examination

Even though the physical exam is centered on the neck, a more systematic comprehensive examination should also be performed.

Inspection of gait and station may reveal postural or structural abnormalities, such as kyphosis, scoliosis, or rotatory malalignment.
Neck range of motion is measured in flexion, extension, right and left rotation, and in the lateral bending planes. The neck and thyroid should be palpated for masses and adenopathy.
The motor examination must include all major muscle groups in the upper extremities and usually in the lower extremities, as well. This should be by the standard 0 (no function) to 5 (normal) scale of strength. Starting distally during this part of the exam may minimize pain and yield better evaluation.
Deep tendon reflexes of the biceps, brachioradialis, triceps, knees, and ankles are graded 0 (not present) to 4 (sustained clonus), with 2/4 documented as normal. Pathologic reflexes, including Babinski and Hoffman's are long tract signs.
The tandem gait, finger-to-nose, and Romberg exams evaluate coordination.
A brief look at a physical examination reference is helpful as a reminder of the specific motor, sensory and deep tendon reflex (DTR) findings for C5, C6, C7 and C8 deficits.
Specific attention must also be given to examination of the shoulder for atrophy, tenderness, range of motion, rotator cuff problems, and impingement.
In cases of cervicobrachialgia, Tinel's test, (percussion over the ulnar nerve at the elbow and median nerve at the wrist) may identify entrapment neuropathies. A brief vascular assessment of the upper extremity may be necessary.

Laboratory and radiological studies

Laboratory testing may be limited to a CBC and erythrocyte sedimentation rate in certain circumstances. X-rays should include an AP and lateral cervical spine, with additional open-mouth odontoid view and obliques, when neurologic symptoms are noted. Flexion-extension views occasionally will reveal instability. Only the consultant should order a myelogram, computerized tomography (CT), and magnetic resonance imaging (MRI).

Differential diagnosis

The differential diagnosis is quite broad and can include congenital and developmental problems (partial fusions), post-traumatic and degenerative problems, and rarely neoplastic, inflammatory, (rheumatoid arthritis or ankylosing spondylitis), infective, or metabolic abnormalities. Most commonly, the problem relates to normal aging changes, disc degeneration, postural and over-use difficulties.

Occasionally, visceral pain is referred to the neck, arm, and shoulder. Anginal pain is referred to the jaw, neck, left shoulder and arm and should always be considered. Vascular, gall bladder, pancreatic, and pulmonary problems can include radiating pain to the posterior thorax, neck, shoulder, and arm. Toxic and metabolic neuropathies can simulate cervical radicular pain. Psychological disorders, such as depression, can exacerbate neck pain; or through postural manifestations can be causally related.

Treatment

Usually after a thorough evaluation (history, physical exam, CBC/ESR and x-rays), a worrisome diagnoses can be ruled out and treatment can be tailored to the common neck complaints. Mild to moderate nonradicular or mild radicular pain and stiffness can be treated with activity modification (light duty to exclude heavy lifting, hard pulling, overhead work, etc.), neck rest, medication acetaminophen, aspirin, or other non-steroidal anti-inflammatory (NSAID) medication, light massage, and ice or heat.

More severe pain or a significant radicular component may require greater activity restriction and addition of a soft cervical collar and time-limited (3-5 days) use of acetaminophen with codeine. Discussion about appropriate neck mechanics is helpful. For mild or chronic symptoms, a physical therapy evaluation with treatment can be helpful to encourage proper posture and proper work positioning to decrease neck stresses. Neck isometric exercises are useful for maintaining tone and strength.

Neck range of motion exercises may aggravate symptoms and probably should not be emphasized. With radicular symptoms, avoidance of neck extension is recommended. Proper pillow selection and use are very helpful since large or firm pillows force neck flexion and increase pain. A soft pillow filling the "hollow" of the neck is beneficial. A pillow pulled into position when turning onto the side may help avoid painful and unprotected lateral neck bending.

Indication for immediate referral

Indications for immediate referral to orthopedics or neurosurgery include the following findings:

Constitutional symptoms or studies (leukocytosis or elevated erythrocyte sedimentation rate) suggesting tumor or infection.
Evidence of spinal cord compression and myelopathy (gait disturbance, Babinski, leg weakness or sphincter disturbance), severe and unremitting arm pain, or progressive neurologic deficit.
Expeditious referral should occur with complaints of pain out-of-proportion, significant nighttime pain, significant arm pain or persistent weakness.
A routine consult should be obtained for chronic neck pain, pain with no objective findings, pain with mild or intermittent paresthesias with normal motor, sensory, and reflex examination. Patients with these problems should be exempted from those portions of the physical readiness program that directly aggravate symptoms (eg. sit-ups, push-ups, etc.).

References

Hoppenfeld, S. Physical Examination of the Spine and Extremities, Appleton-Century-Crotts, 1976.
Sherk, H. & Cervical Spine Research Society Editorial Committee. The Cervical Spine. Lippincott. 1989.

Reviewed by CAPT John S. Webster, MC, USN, Chairman, Orthopedic Department, Residency Program Director, Naval Medical Center San Diego, and LCDR Geoffrey McCullen, MC, USNR, Director, Orthopedic Spine Service, Naval Medical Center San Diego, San Diego, CA (1999).

Preface · Administrative Section · Clinical Section

The General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C., 20372-5300

This web version of The General Medical Officer Manual, NAVMEDPUB 5134 is provided by The Brookside Associates Medical Education Division. It contains original contents from the official US Navy version, but has been reformatted for web access and includes advertising and links that were not present in the original version. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense. All material in this version is unclassified. This formatting © 2006 Medical Education Division, Brookside Associates, Ltd. All rights reserved.

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