CKS: Clinical solutions - Non-specific neck pain

The Case: A 45-year-old IT worker comes to see you with a two-week history of neck pain, which sometimes reaches into his shoulders or gives him a headache.

Non-specific neck pain
Non-specific neck pain

How do I make the diagnosis?
Non-specific neck pain has no specific underlying disease causing the pain.

Exclude specific causes of neck pain, including serious spinal abnormality, whiplash injury, acute torticollis, cervical radiculopathy and non-musculoskeletal causes by looking for red flags.

Suspect non-specific neck pain if the pain varies with different physical activities.

Non-specific neck pain often radiates in a non-segmental distribution down the arm, into the head and shoulder, or across the shoulder blades. There may be stiffness, spasm, headache or pain in the spine. Typically there is poorly localised tenderness of muscles. There is no loss of sensation or muscle strength.

Red flags
The following indicate a serious underlying cause is more likely:

  • New symptoms before the age of 20 years or after the age of 55 years.
  • Weakness in more than one myotome or loss of sensation involving more than one dermatome, and intractable or increasing pain.
  • A history of inflammatory arthritis, immunosuppression, cancer, TB, drug abuse, AIDS or other infection.
  • Malaise, fever, unexplained weight loss.
  • Pain that is unremitting or disturbs sleep.
  • Lymphadenopathy and exquisite tenderness over a vertebral body.
  • A history of violent trauma (e.g. a road traffic accident or a fall from height) or a history of neck surgery.

What may indicate spinal cord compression?
Gait disturbance, clumsy or weak hands, loss of sexual, bladder or bowel function may indicate spinal cord compression.

Lhermitte's sign: flexion of the neck causes a shock-type sensation that radiates down the spine and into the limbs.

Look for upper motor neuron signs in the lower limbs (Babinski's sign - up-going plantar reflex, hyperreflexia, clonus, spasticity). Lower motor neuron signs in the upper limbs (atrophy, hyporeflexia).

How should I assess him?
X-rays and imaging studies are not routinely required.

Identify risk factors such as awkward neck posture, neck flexion, arm force or hand-arm vibration. Psychosocial factors may indicate increased risk for chronicity and disability.

Evidence
CKS has derived the recommendations for the diagnosis of non-specific neck pain from review articles1,2 and a primary care textbook.3 Evidence from prospective cohort and cross-sectional studies suggests that psychosocial factors and a high physical workload are important risk factors for neck pain.4-9

References

1. Binder AI. BMJ 2007; 334: 527-31.

2. Binder A. Eura Medicophys 2007; 43: 79-89.

3. Williams NH, Hoving JL. In: Jones R, Britten N, Culpepper L. et al. (Eds.) Oxford textbook of primary medical care. Oxford, Oxford University Press, 2005.

4. Ostergren PO, Hanson BS, Balogh I et al. J Epidemiol Com Health 2005; 59: 721-8.

5. Sim J, Lacey RJ, Lewis M. BMC Public Health 2006; 6: 234.

6. Hogg-Johnson S, van der Velde G, Carroll LJ et al. Eur Spine J 2008; 17(Suppl 1): S39-S51.

7.Carroll LJ, Cassidy JD, Cote P. Depression as a risk factor for onset of an episode of troublesome neck and low back pain. Pain 2004; 107: 134-9.

8. Johnston V, Souvlis T, Jimmieson NL, Jull G. Appl Ergon 2008; 39: 171-82.

9.Andersen JH, Kaergaard A, Mikkelsen S et al. Occup Environ Med 2003; 60: 649-54.

GP CKS - Reliable, evidence-based answers to real-life clinical questions, from the NHS Clinical Knowledge Summaries in association with GP.

See www.cks.nhs.uk

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