Clinical Features

The source of neck pain can often be determined by a thorough and searching history. In most cases, patients can identify the inciting event or an exacerbating maneuver or position that causes pain. Following trauma, note the exact nature of the impact with reference to positioning; accompanying lacerations of the head, neck, or face; the use of restraints; the use of protective sports equipment; associated limb or trunk fractures or contusions; and loss of consciousness or seizures. The date of injury, the patient's age and occupation, preexisting medical conditions, and other contributing factors should also be identified. Determine the character of pain and its distribution. Ask about specific neurogenic symptoms, including extremity weakness, incoordination, numbness or paresthesias, and sphincter and sexual dysfunction. Patients with visual, auditory-vestibular, and pharyngeal-laryngeal symptoms often require direct questioning to elicit complaints. The results of previous imaging studies and prior response to medication or physical treatment may be diagnostic.

The physical examination begins with an observation of a loss of neck flexibility, unless a mechanism of injury is present for possible cervical fracture or spinal cord injury. In such cases, the neck should remain immobilized until radiographs are obtained and reviewed by the emergency physician. Pain may cause splinting of the head on the shoulders during position change. Active and passive movement should be assessed, including rotation (chin to shoulder) and lateral flexion (ear to shoulder). When localized ipsilateral neck pain is experienced toward the side of head movement, zygoapophyseal joint irritability is suspected. When ipsilateral pain radiates to shoulder or arm (Spurling sign), a radicular component may be present. Contralateral neck pain suggests either a primary ligamentous or a muscular source of discomfort as these structures are stretched.

Palpate the posterior cervical triangle, the supraclavicular fossa, and carotid sheaths, and the anterior neck. Auscultation of the carotid and the subclavian arteries may demonstrate bruits, in the former associated with potential cerebral insufficiency and in the latter instance with a thoracic outlet or vascular steal syndrome. Symptomatic occipital neuralgia can be replicated by firm pressure over the occipital notch, producing scalp numbness or burning dysesthesias in the occipital nerve distribution. Various compression and distraction maneuvers of the cervical spine are also diagnostically useful. They include vertical skull compression or lateral flexion positions that replicate radicular symptoms and manual vertical distraction, a reverse Spurling maneuver, which "unloads" the spinal roots and adjacent cervical vertebral joints, thereby reducing pain.

An evaluation of neck discomfort is incomplete without shoulder, arm, and neurologic examination (Iable 273-1), since cervical spinal radiculopathies can cause upper extremity pain, paresthesias, and weakness. Knowledge of the dermatome, sclerotome, and myotome referral distribution of spinal root irritation is also essential to diagnosis. Look for muscle atrophy or fasciculations. A loss of triceps reflex suggests C7 root pathology, whereas a loss of biceps reflex suggests a C5-C6 root syndrome. Motor strength is tested by the "break" maneuver, whereby the patient is given a maximal advantage of position and strength and the examiner "breaks" the muscle, comparing one side with the other. The triceps is tested by having the patient extend the elbow and maximally resist the examiner's efforts to flex the elbow. A smooth, asymmetric "give" rather than a "ratchety" break suggests C7-C8, posterior cord, or radial nerve involvement. Similarly, other muscle groups are tested and patterns of weakness are correlated with the clinical history and symptoms. Local nerve palpation also is a useful adjunct to the examination. C5-C6 root lesions often elicit tenderness over the brachial plexus at Erb's point in the supraclavicular fossa, whereas a C8-T1 root lesion can cause tenderness over the distal ulnar nerve at the elbow.

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