Monday Morning Patients: Pains in the Neck . . .
In many outpatient practices, Monday morning is the time when new patients are evaluated. Squeezing in new patients between routine follow-ups can make Mondays especially hectic. This is the first installment of a new editorial feature that focuses on typical Monday morning patients—each with the same chief clinical complaint, but with different causes. I invite you to read the cases of 4 patients whose chief complaint is a 2-week history of neck pain. Each patient went to the emergency department over the weekend and received an MRI scan of the neck. “Degenerative disk disease” was diagnosed in the 3 adult patients. “Neck strain” was diagnosed in the adolescent. All patients were advised to follow up with their primary care doctor on Monday. Try your hand at making a quick diagnosis . . . then turn the page to read the outcome. Although these chief complaints and brief histories are typical, none of these 4 patients has provided enough information to formulate an educated diagnosis. Even though each patient has the same primary complaint, differences in history and examination provide ready clues to diagnostic possibilities. Extracting these important features depends on a targeted evaluation that focuses on high-yield questions and on examination findings that help distinguish among the many possible causes of neck pain. A HIGH-YIELD, TARGETED EVALUATION OF NECK PAIN The same examination principles apply to each patient regarding features in the history, physical examination findings, and the need to proceed with testing. Details of the targeted examination are outlined in the Table. It is important to target specific examinations to specific clinical scenarios to help confirm or refute clinical diagnoses. Imaging studies of the spine are notorious for producing false-positive results. For example, degenerative cervical disk disease—the putative diagnosis for each of the adult patients presented here—has been identified on MRI scans in 25% of asymptomatic persons younger than 40 years and in nearly 60% of asymptomatic persons 40 years and older.1,2 In another MRI study of symptom-free young adults (ages 24 to 26 years), MRIs identified cervical disk degeneration in 29% and disk bulges in 32%.3 Similarly, plain x-ray films become “abnormal” with aging—even in asymptomatic persons. Patient No. 1 Mrs Dean, the 42-year-old obese nurse HISTORY •Her neck pain began after she lifted a heavy patient at work. •She notices pain going into her right hand. •Since the pain began, she has had a tingling in her right middle finger. •She had a “slipped disk” in her low back 7 years earlier. TARGETED EXAMINATION •Active range of motion is restricted because of pain, but she has full passive range of motion when the examiner moves her relaxed neck. •Neurologic examination of the right upper extremity shows reduced strength with arm extension at the elbow, depressed triceps reflex, and numbness over the palm and middle finger. Reflexes, strength, and sensation are normal in the other extremities. Gait is normal. TESTING •Electromyography (EMG) and nerve conduction studies confirmed a right C7 radiculopathy. •Cervical MRI shows a right-sided herniated disk at C6-7. DIAGNOSIS: RIGHT C7 RADICULOPATHY Mrs Dean has several risk factors for radiculopathy, including obesity, heavy work duties, and a history of lumbar disk disease. A survey of 561 patients with cervical radiculopathy revealed a history of lumbar radiculopathy in 41%.4 Physical examination shows good range of motion of the cervical joints and a C7 cervical radiculopathy. The clinical impression of cervical radiculopathy is confirmed by both EMG and MRI testing. A survey of patients with clinically diagnosed cervical radiculopathy found EMG abnormalities in 52% and MRI abnormalities in 48%.5 As expected, an abnormal result on either test was most frequent in patients like Mrs Dean, who have more definite clinical signs of radiculopathy. PATIENT NO. 2 Ms Jeffries, the 14-year-old high school student HISTORY: •She gets bouts of neck pain about twice a month—and always with her menstrual period. •When she gets neck pain and tenderness, she usually tries to go home to sleep. When she does, she wakes up in a couple of hours feeling fine. If she can’t go to sleep, the pain creeps over her head until one side of her head is throbbing and she feels nauseated. If she can’t go right to sleep, she’ll usually throw up and then feel better. •She rarely has these bouts of neck pain during school vacations or on weekends. TARGETED EXAMINATION •Full range of motion of her neck, with mild tenderness over the trapezius muscles bilaterally. •Normal neurologic screening examination results. TESTING •No testing is ordered. DIAGNOSIS: MIGRAINE WITH NECK PAIN Migraine is often preceded by or associated with neck pain. In one study, neck pain associated with migraine attacks was reported by 70% of 200 migraineurs without aura.6 Migraineurs often report a significant association between neck symptoms and migraine, including headache beginning with neck pain, headache associated with aggravation of neck pain, and neck tenderness during migraine.7 Physical examination may identify myofascial trigger points in 79% of migraineurs.8 Mechanical or joint dysfunction is rarely identified in migraineurs.8 As is common in children and adolescents, Ms Jeffries’s migraines typically occur with menses and school stress. A survey of 320 children with chronic headache showed a strong association between school and migraine.9 In that study, 80% of children who had migraine without aura had significant improvement or complete relief of attacks during school breaks (like Ms Jeffries). In only 30% of migraineurs were afterschool activities limited. Sleep deficiency and exposure to computers were also identified as significant headache triggers. Migraine attacks are typically aggravated in girls during adolescence, possibly because of hormonal changes of puberty, changes in sleep patterns, and increased school stress. PATIENT NO. 3 Mr Sanford, the 36-year-old mechanic HISTORY •About 1 week after the neck pain started, Mr Sanford noticed some tingling and numbness in his hand, as well as dizziness. •Mr Sanford is a smoker. He is currently being treated for both hypertension and hypercholesterolemia. TARGETED EXAMINATION •There are no restrictions of active neck movement. •His eyelid is slightly drooped on the left, and sensation is decreased over the left side of the face. Sensation to pinprick is decreased in the right upper extremity. •While walking, he tends to fall toward the left. TESTING •An MRI scan of the brain shows an infarct in the lateral medulla. A crescent-shaped high signal is noted at the left vertebral artery; this is consistent with a hematoma. •Narrowing of the lumen in a segment of the left vertebral artery (string sign) is identified on angiography. DIAGNOSIS: LEFT VERTEBRAL ARTERY DISSECTION Vertebral artery dissection may occur after neck manipulation, trauma (eg, whiplash injury), sports or exercise, or prolonged working in cramped spaces (as in Mr Sanford’s case).10,11 In one survey of 46 patients with vertebral artery dissection, neck pain was reported by 72% and headache by 50%.11 In a similar report of 26 patients with vertebral artery dissection, pain involving the neck or head (predominantly occipital) was a prominent feature in 85% and preceded the development of neurologic deficits in 53%.12 Vertebral artery dissection occurs in men slightly more often than in women (59% vs 41%), with a mean age at onset of 42 years.11 Hypertension, hypercholesterolemia, and smoking are all risk factors for vertebral artery dissection.11 Mr Sanford’s clinical presentation is typical for lateral medullary infarction or Wallenberg syndrome: facial numbness; Horner syndrome; and ataxia on the side of the infarction, with extremity numbness to pinprick and temperature on the opposite side. PATIENT NO. 4 Mrs Grace, the 67-year-old retired schoolteacher HISTORY •When she holds her head in one position for a long time (eg, when painting high walls or ceilings), the neck pain radiates over the back and side of her head. TARGETED EXAMINATION •Active and passive range of motion of the cervical spine is decreased. As the relaxed neck is passively moved, crepitus may be appreciated. The paraspinal muscles are tender, and palpation triggers a head pain. •Results of the neurologic screen are normal. TESTING •X-ray films of the cervical spine show several large osteophytes and disk-space narrowing. DIAGNOSIS: OSTEOARTHRITIS WITH CERVICOGENIC HEADACHE Cervicogenic headache is defined as headache that occurs with symptoms and signs of neck pain.13 Neck pain is a prominent feature, and head pain is typically provoked by neck movements, prolonged posture, or palpation. Cervical range of motion is also typically decreased, as in this patient. Significant cervical pathology may be identified with imaging studies. Women are 4 times more likely than men to have cervicogenic headache; the mean age at onset is 43 years.14 In the United States, osteoarthritis affects 68% of adults 55 years and older.15 Osteoarthritis generally affects the spine and large weight-bearing joints. Osteoarthritis pain typically worsens with activity. Morning stiffness is also common. As with Mrs Grace, the typical physical examination shows joint tenderness, crepitus on motion, and restricted passive range of motion. NOT EVERY PAIN IN THE NECK IS CERVICAL Although each of these 4 patients presented with neck pain, the cervical spine was not the origin of symptoms for each. A high-yield, targeted history and examination can help you achieve quick and accurate diagnoses. So the next time you see a “pain in the neck” in your office, remember that neck pain may be associated with a variety of clinical diagnoses. REFERENCES 1. Boden SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72:1178-1184. 2. Lehto IJ, Tertti MO, Komu ME, et al. Age-related MRI changes at 0.1 T in cervical discs in asymptomatic subjects. Neuroradiology. 1994;36:49-53. 3. Siivola SM, Levoska S, Tervonen O, et al. MRI changes of cervical spine in asymptomatic and symptomatic young adults. Eur Spine J. 2002;11: 358-363. 4. Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117:325-335. 5. Nardin RA, Patel MR, Gudas TF, et al. Electromyography and magnetic resonance imaging in the evaluation of radiculopathy. Muscle Nerve. 1999; 22:151-155. 6. de Queiroz LP, Rapoport AM, Sheftell FD. Clinical characteristics of migraine without aura [in Portuguese]. Arq Neuropsiquiatr. 1998;56:78-82. 7. Fishbain DA, Cutler R, Cole B, et al. International Headache Society headache diagnostic patterns in pain facility patients. Clin J Pain. 2001;17:78-93. 8. Marcus DA, Scharff L, Mercer S, Turk DC. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache. 1999;39:21-27. 9. Rossi LN, Cortinovis I, Menegazzo L, et al. Classification criteria and distinction between migraine and tension-type headache in children. Dev Med Child Neurol. 2001;43:45-51. 10. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60:1424-1428. 11. Dziewas R, Konrad C, Dräger B, et al. Cervical artery dissection—clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003;250: 1179-1184. 12. Saeed AB, Shuaib A, Al-Sulaiti G, Emery D. Vertebral artery dissection: warning symptoms, clinical features and prognosis in 26 patients. Can J Neurol Sci. 2000;27:292-296. 13. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache. 1998;38:442-445. 14. Haldeman S, Dagenais S. Cervicogenic headaches: a critical review. Spine J. 2001;1:31-46. 15. Elders MJ. The increasing impact of arthritis on public health. J Rheumatol Suppl. 2000;60:6-8