THE PAINFUL NECK

1. 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.

2. THE PAINFUL NECK 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.

3. THE PAINFUL NECK • 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.

4. THE PAINFUL NECK • 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.

5. THE PAINFUL NECK • 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.

6. THE PAINFUL NECK • 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

7. THE PAINFUL NECK • 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).

8. THE PAINFUL NECK • 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.

9. THE PAINFUL NECK • 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.

10. THE PAINFUL NECK • 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.

11. THE PAINFUL NECK • 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.

12. THE PAINFUL NECK • 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.

13. THE PAINFUL NECK • 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 occiputo-cervical 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 tell the patient that he has a “terrible cervical osteoarthrosis“!

14. THE PAINFUL NECK • 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.

15. THE PAINFUL NECK • 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.

16. THE PAINFUL NECK • 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.

17. THE PAINFUL NECK • 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.

18. THE PAINFUL NECK Therapeutic guide Treatment of neck pain and cervicobrachialgias Aims: • Suppression of the pain • Restoration of physiological movement.

19. THE PAINFUL NECK 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.

20. THE PAINFUL NECK 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.

21. THE PAINFUL NECK Therapeutic guide Treatment of neck pain and cervicobrachialgias In the sub-acute stage Passive physiotherapy: Most patient find muscle-relaxing 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.

22. THE PAINFUL NECK 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.

23. THE PAINFUL NECK Treatment of the levator scapulae syndrome Aims: • Reduction of the pain. • Relaxation of the mucles. • Prevention of recurrence.

24. THE PAINFUL NECK • 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