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Neck Pain Cheat Sheet (DRAFT) by

Neck Pain Hx & Definition

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Anatomy in the neck

Lymph nodes
Thyroid + parath­­yroid gland
Salivary Gland
Blood Vessels
Muscles, bones, cartilage
Nerves
Oesophagus + trachea

Cervical Lymphnodes

Non-MSK causes of neck pain

Oesoph­agus: Indige­stion, Difficulty swallowing
Thyroid: Enlarg­ement, Infect­ion­/In­fla­mma­tion, cancer
Carotid Artery: Dissection
Lymph nodes: Infect­ion­/in­fla­mma­tion, cancer - Submental, Subman­dibula, Tonsillar, Parotid, Preaur­icular, Postau­ric­ular, Occupital, Anterior cx, Posterior cx, Suprac­lav­icular
Heart: MI/IHD - refer to neck and jaw + down left arm
Lung: Apical Tumours - refer to neck, shoulder and arm
- Consider
Age, Hx of the lump, Location of the lump, Exam of the lump, Exam of the head/neck

Questions to ask

Pain related to exertion, relieved bby rest? Risk factors of IHD/Ca­rdiac issues
Respir­atory symptoms? Smoker?
Swellings in the neck? (lymph­nod­es/­thy­roid?) - How long? Where is it? How was it noticed? Enlarging or changing? Local symptoms? Other symptoms? Other lumps? Hx of cancer? Smokin­g/a­lcohol? Travel­/tr­auma?
GI Symptoms?
Hx of neck traum/­hea­dac­he/­visual distur­ban­ces­/ne­uro­logical symptoms?
Recent infect­ions/ hx of cancer?
- Lumps should reduce within 6 weeks , if not, consider possible malignancy (should be seen within 2 weeks)
- Painful nodes = infection
- Firm, hard, painless = cancer

Neck Pain Causes

- Pain from superior nuchal line to the tip of T1 , sagittal planes
Caused by:
Myofascial Pain Syndrome
 
Interv­ert­ebral Joint Hypomo­bility
 
Spondy­losis
 
Muscul­oli­gam­entous strain­/sprain
 
Interv­ert­ebral Disc Derang­ement
 
Serious Disorders
Mening­iti­s/SAH
 
Angina/MI referral
 
Metastasis
 
Vascular Lesions
 
Oesoph­ageal Disorders
 
Pitfalls
RA
 
PMR
 
Fibrom­yalgia
 
Myelopathy - look for stiffness of the legs
Lumps:
Children: Reactive lympad­eno­pathy - infections in head/n­eck­/co­nge­nital cysts
Young adults: Inflam­mat­ion­/in­fection - Viral/­bac­terial adenitis, Thyroid cancer
>40s : Malignant until proven otherwise

Refer

- Refer to GP when:
- Symptoms of Cx radioc­ulo­pathy persis­ts/not improved with conser­vative management within 4 weeks
- Clinical Evidence of NR compromise
- Incapa­cit­ating Neck/Arm Pain

Injury Mechnisms

- CT best for fractures, MRI better for soft tissure damage
- F# commonly @ C1-2, C5-7 & T12-L2
- Four types of Spinal F#/Dis­loc­ation
1. Compre­ssion 2. Burst 3. Seat Belt Injuries 4. Fracture- Disloc­ations
Compre­ssion:
Hyperf­lexion + Axial Compre­ssion - usually posterior height is maintained
Burst Fractures
Axial loading of the spine
Seat-Belt
Rapid Decele­ration - Axis, middle + posterior structures affected

Invest­iga­tions

Canadian C-Spine Rules
For Alert (GCS = 15) pts over 16 after trauma
High Risk Factor
- >65 yo or Dangerous Mechanism of injury­/Pa­res­thesia in Extrem­ities
Low Risk Factor - allows safe assessment of ROM
- Simple Rear End Collision
 
- Sitting Position in Emergency Department
 
- Walking at any time
 
- Delayed onset of Neck Pain
 
- Absence of Midline Cx tenderness
Are they able to turn their heads Left and Right 45 degrees
N/A for <16, GCS <15, Acute Paralysis, Known Vertebral Disease/ previous surgery
Dangerous Mechanism of Injury = Fall from elevation >3 ft/five stairs, axial load to head, high speed vehicle accidents (>1­00k­m/h), rollover, ejection, motorised recrea­tional vehicles, bicycl­e/c­oll­isions

Features in the history

Location
- Locali­sed­/Ra­diating
 
- Localised = Muscle strain, ligament sprains, manipu­lable lesions, facet joint/disc degene­ration - Radiation into the arm = nerve/­MTrps
 
Charac­ter­istics of pain
Sharp (acute) Dull/a­ching (Chronic) = Muscle­/li­gam­ent­/disc
 
Deep/B­oring pain = Bone/joint
 
Electr­ical, numbing, tingling, shooting = neurogenic
 
Onset
Trauma? Anything that set it off? Life/A­ctivity changes prior to the onset?
 
Aggrav­ating & Relieving Factors
Pain during neck extension - compre­ssion of posterior elements - Usually the Facet Joints, consider NR if pain radiates down Arm
 
- Pain with overhead Activities Consider TOS
 
- Pain at the end of the day = chronic overuse, mechanical disorder, degene­ration
 
Pain duration
Muscle strains = Recover in a few days to a couple of weeks
 
Ligament Sprains = Up to a couple of months
 
Disc Injuri­es/­her­niation = 3-6 months
 
Chronic Pain = >6 months - degene­rative, mechanical instab­ility, chronic inflam­mat­ory­/ne­uro­pathic process
 
Associated symptoms
Arm symptoms (pain, paraes­thesia, weakness, clumsi­ness)
 
Headaches, dizziness, nausea
 
Difficulty Walking - scuffing of toes, feeling unbalanced (CSM)
 
- Did they come on the same time as your complaint?

Red Flags

Condition
Red Flags
F#
Trauma, Loss of consci­ous­ness, Thrown from a vehicle, inability to move neck due to pain, Rust's sign, use of high does Steroids, Pain on Percussion
Tumour
>50 yo, Pain at rest, Unexpl­ained weight loss, Hx of cancer, Failure to improve with previous treatm­ents, Dysphagia, Headache, Vomiting, Pain on Percussion
Infection
Systemic S&S, Risk factors ( immuno­sup­pre­sion, underlying disease, penetr­ating wound, exposure to infectious disease), Intrav­enous Drug use, Pain at rest, Nuchal rigidity, Pain on Percussion
Spinal Cord Compre­ssion
Trauma to the neck, Paraes­thesias of upper and or lower extrem­ities, Difficulty walkin­g/stiff gait, Babinski + Hoffman +ve, Hypera­ctive Reflexes, Ankle Clonus
Cerebr­al/­Spinal Haemor­rhage
Cerebr­ova­scular sympto­ms/­signs, Antico­agulant Use
Verteb­ral­/Ca­rotid Aneurysm
Cardio­vas­cular Risk Factors, TIA

Neck Pain in Children

Consider:
Infection, inflam­mation of cx lymphnodes - tonsil­iti­es/­pha­ryn­gitis. Mening­itis, acute tortic­ollis - Chronic Junvenile Arthritis

Neck Pain in the Elderly

Consider:
- Cx spondy­losis with radicu­lop­ath­y/m­yel­opathy
 
- Atlant­oaxial Sublux­ation - RA
 
- PMR
 
- Metastatic Cancer
 
- Pancoast Tumour
 
- Angina/MI
 
- Pharyngeal & Retrop­har­yngeal infect­ion­/tumour

Lumps Where?

Midline: Thyroid swellings, Thyrog­lossal cyst, Submental lymph nodes
Lateral (anterior triangle): Thyroid swellings, Subman­dibular gland swelling, Lymph nodes, Parotid swellings
Lateral (poste­rior) : Lymph nodes, Carotid artery aneurysm, Cx ribs

Neck Lumps

Exam

Site, Size, Shape, Surface (4 S's)
Consis­tency, Colour, Compre­ssi­ble­/fl­uctuant (3 C's)
Transi­llu­min­ation, Tender­ness, Tethered (3 T's)

Autoimmune

Diabetes
RA
Pernicious Anaemia
Hashimotos
MS
SLE
Vitiligo

Thyroid Anatomy

Thyroid Physiology

Palpating the thyroid

Hypoth­yro­idism

- If goitre = Hashim­otos, if no goitre = Atrophic primary hypoth­yro­idism
- Caused by: Hashim­otos, Surger­y/r­adi­oactive treatment to the thyroid ,Side effect of medica­tions (Amiod­arone, Lithium), Iodine defici­ency, Pituitary Tumour
Symptoms: Tiredness, Lethary, Xathomas, Consti­pia­tion, Intole­rance to cold, Muscle stiffness, Cramps, CTS, Menorr­hagia, Slowing of intell­ectual activity, Reduced motor activity, decreased appetite, weight gain, Dry skin + hair loss, Deep, hoarse voice
Signs: Expres­sio­nless, dull face with perorbital + tongue swelling, Sparse hair, Pale cool skin with rough, doughy texture, Coarse dry brittle hair, Goitre, Bradyc­ardia, Obesity, Prolonged relaxation phase of DTR, Peripheral neuropathy
- Thyroxine

Hypert­hyr­oidism

- Grave's disease
Symptoms: Restless, nervous, emotional irritable, sleeping poorly, Tremour of the hands, Losing weight, Palpit­ations, Sweating and dislike of heat, Diarrhoea, SOB, Menstrual changes (light­/in­fre­quent), SKin problems - hair thinning, itching. Increased thirst, Tiredness + muscle weakness
Signs: Sinus Tachyc­ardia (can be atrial fib), Fine tremour, Warm, moist skin, Goitre, Hyperr­efl­exia, Proximal Myopathy, muscles weakness and wasting, exopth­almus
- Medica­tion:: Beta blockers, Carbim­azole , Surgery: Thyroi­dec­tomy, Radio Iodine (kills iodine producing cells)
Exam: Observe + Palpate Thyroid gland with two hands standing behind the patient, get patient to swallow Normally, gland is not palpable unless enlarged!