Neck Pain

Dzung H. Dinh, MD, MBA

Professor of Neurosurgery

University of Illinois College of Medicine at Peoria

Disclosure

Aesculap

ROI

Nuvasive

Content

1. Anatomy2. Evaluation of neck pain3. Differential diagnosis4. Treatment plan

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Evaluation

1. History1. Ask the right questions

2. Listen to the patient

3. Formulate a diagnosis

2. Examination1. To confirm your diagnosis, not to make diagnosis

3. Ordering additional tests1. Again, to confirm or r/o diagnosis.

HistoryAsk the right questions

Critical questions1. Pain location

Central/Axial/Paraspinal Refer HA or Arm Sx True Radicular

2. Pain quality Dull ache Sharp shooting –neck, occiput,

arm Burning vs. dysesthesia

3. Pain Pattern - Diffuse Discrete

4. Numbness – pattern, location

5. Deficit – pattern/distribution

Not so critical questions

1. Pain onset/inciting event

2. Pain provocation3. Pain diminution4. Up-to-date Rx

HistoryListen to the patient

Stumbling gaitDropping thingsHand falling asleepSkin feels burntTrouble going upstairUrinary hesitancyNo painWoke up with weaknessSlowly getting worse

HistoryDiagnosis formulation

Diffuse neck pain, HA, skin burning, TP – myofascial pain.

Discrete arm pain, not much neck pain, discrete deficit – radiculopathy

Weakness, no pain, no numbness – ALSHand numbness in median or ulnar pattern-

CTS or cubbital Sx

Wrist extensor weakness- C7 or radial nerve

Radicular sx and entrapment sx - Double crush syndrome (C5 or 6 and CTS, C8 or T1 and ulnar)

Examinationto confirm your diagnosis

Myofascial pain: Trigger points (supraspinatus, rhomboid, teres), no deficit

Myelopathy: spastic gait, hyperreflexia, path reflex

Radicular distribution deficit – radicularC5: deltoid, infra/supraspinatusC6: bicep, dorsal forarm, thumb, index fingerC7: tricep, index, middle finger, finger, wrist extensionC8: 4th,5th fingers, volar of forearm, grip weaknessT1: under arm, finger extension.

Peripheral entrapment CTS: middle 3 fingers, grip weakness, + PhalenCubittal Sx: last 2 fingers, opponens, + TinelRadial nerve pathology

Additional Teststo confirm your diagnosis

Myofascial pain- EMG/NCV if there is lots of refer Sx

Myelopathy: MRI Radicular – MRIPeripheral entrapment – EMG/NCV

Treatment Plan

1. Myelopathy with cord compression – surgery

2. Radiculopathy with deficit – surgery +/-

3. Myofascial Pain – Never surgery

4. Peripheral Entrapment Sx - Maybe

5. Double crush Sx – Depends

6. Radiculopathy and Myofascial Pain - depends

Case Presentation

Thank You