causes and management of neck pain

1. CERVICAL PAIN
Dr Minhaj Akhter
Post-Doctoral Fellow
Pain and Palliative Care
Department of Anaesthesiology and Critical Care
AIIMS, Jodhpur

38. • Alignment: assess the alignment of all relevant views (e.g.
lateral, AP and open mouth)
• Bones: assess each of the vertebrae, inspecting the cortex
for irregularities
• Cartilage: assess the height of each intervertebral disc
• Soft tissue: assess the pre-vertebral soft tissue width, for
evidence of swelling

45. Cervical Strain and Sprains
• Associated with headaches
• Sharp or dull and localize to the cervical or shoulder girdle musculature
• Patient can also report neck fatigue or stiffness that lessens with gradual
activity
• Aggravating factors include passive or active motion
• Decreased cervical range of motion can be detected on gross examination
• Palpation of the involved region is usually uncomfortable or moderately
painful
• The most commonly involved areas are the upper trapezius and
sternocleidomastoid muscles

47. • Nonsteroidal antiinflammatory drugs (NSAIDs) and
acetaminophen
• If patients complain of substantial “spasm” that is not
ameliorated by analgesics and proper positioning,
tizanidine or tricyclic antidepressants may be helpful
• Physical modalities such as massage, superficial and deep
heat, electrical stimulation, and a soft cervical collar can be
employed in the treatment program
• A gradual return to activities should be initiated by 2 to 4
weeks after injury, and should include a functional
restoration program to address postural reeducation and
functional biomechanical deficits
• Proprioceptive retraining, balance, and postural
conditioning should be incorporated into the exercise
regimen
• Flexibility and range of motion are improved by
mobilization and stretching exercises

48. Cervical Radiculopathy and Radicular Pain
• Cervical radiculopathy is a pathologic process involving neurophysiologic
dysfunction of the nerve root with myotomal weakness, paresthesias, sensory
disturbances, and depressed muscle stretch reflexes
• Cervical radicular pain represents a hyperexcitable state of the affected nerve
root
• Cervical nerve root injury is most commonly due to cervical intervertebral disk
herniation (CIDH), secondly to spondylitic changes
• Patient education, activity modification, avoid repetitive and heavy lifting , as well
as positioning the cervical spine in extension, axial rotation, and ipsilateral flexion
• Severe pain can prohibit continued work or athletic activity and restrict activities
of daily living

49. • Cold can be applied for 15 to 30 minutes 1 to 4 times a day, and superficial heat
can be applied up to 30 minutes 2 to 3 times a day
• TENS, Cervical tractiont
• NSAIDs with or without muscle relxers
• Low-dose tricyclic antidepressant medications and antiepleptics
• Opiate analgesics – severe radicular and disrupts sleep
• Functional restoration includes biomechanical concerns, physical conditioning,
and strength training
• Diagnostic and therapeutic Selective Nerve Root Block
• Percutaneous Diskectomy/Disk Decompression

50. Cervical Joint Pain
• Cervical zygapophyseal joints are a common source of chronic posttraumatic neck
pain
• Unilateral paramidline neck pain, with or without periscapular symptoms, that is
more painful than any associated headaches, suggests zygapophyseal joint pain
rather than disk or root injury
• NSAIDs , Superficial cryotherapy
• Soft tissue mobilization and massage, Crvicothoracic stabilization
• Diagnostic and therapeutic Zygapophyseal Joint Blocks
• Medial branch block
• Percutaneous Radiofrequency Ablation Medial Branch Neurotomy
• Ablation of the third occipital nerve has been shown to successfully treat C2–3
joint pain

51. Cervical Internal Disk Disruption
• Symptom- posterior neck pain, occipital and suboccipital pain, upper trapezial
pain, inter- and periscapular pain, nonradicular arm pain, vertigo, tinnitus, ocular
dysfunction, dysphagia, facial pain, and anterior chest wall pain
• Cervical extension and lateral bending are more restricted than flexion and axial
rotation are
• Palpation over the cervical spinous processes of the involved level can elicit pain
in that region or a portion of the patient’s axial pain
• MRI- Disk desiccation, loss of disk height, annular fissure, osteophytosis, and
reactive end-plate changes are markers of disk degeneration

53. • NSAIDs, Physical modalities
• TENS therapy
• Traction might be beneficial by distracting painful intervertebral disks
• Cervical collars
• Cervical spine stabilization rather than just stretching and strengthening is
supported
• Provocation diskography is a functional diagnostic test
• Proponents of diskography suggest that healthy disks accept a finite volume of
contrast and do not produce symptoms with mechanical stimulation
• Transforaminal Epidural Steroid Injections
• The only surgical treatment for CIDD or symptomatic cervical degenerative disks is
fusion

54. Cervicogenic Headaches
• Various spine structures have been implicated in cervicogenic headache,
including nerve roots and spinal nerves, dorsal root ganglia, uncovertebral joints,
intervertebral disks, facet joints, ligaments, and muscles
• C2–3 zygapophyseal joint and the C2–3, C3–4, C4–5, and C5–6 intervertebral
disks have been primarily implicated as sources of cervicogenic headache
• Deep ache to sharp and stabbing
• Patients often describe the pain as initiating in the cervical region and traveling to
the head and the neck as the pain becomes severe
• Accompanying complaints of dizziness or vertigo
• If the cervicogenic headache is being produced by a cervical zygapophyseal joint,
the patient can usually pinpoint with one finger or with the palm of the hand a
unilateral area of maximal pain
• Cervical intervertebral disk-induced cervicogenic headache typically begins as
midline pain that spreads across the spine and into the head or face

55. • Certain head and neck movements can precipitate painful symptoms, such as
axial rotation or cervical extension
• Spurling maneuver does not reproduce upper limb radicular symptoms but
usually aggravates the axial pain, and patients report reproduction of their
Paramidline zygapophyseal joint-mediated pain
• Cervicogenic headaches due to upper cervical zygapophyseal joint pain can be
studied with confirmatory diagnostic blockade
• The traditional algorithm includes diagnostic blocks performed sequentially at the
C3–4, and C1–2 joints after assessing the C2–3 joint by third occipital nerve
blockade
• Blockade of the C4–5 zygapophyseal joints if the headaches include anterior head
or facial symptoms
• Once the painful joint is identified, therapeutic procedures are performed

57. EXERCISES FOR MECHANICAL NECK DISORDER

59. THANK YOU