Neck and Back January 2013

Report
Neck Pain
LEARNING NEEDS?
Case Study
 On call – telephone consultation
 8 year old daughter with left sided neck pain
 Woke up this am
 Won’t move her neck
Examination
 Tenderness is often diffuse
 Trigger points
 Restricted or painful movement
Acute Torticollis
 Sudden onset
 Severe and unilateral
 Deviation of neck – neck feels stuck
 Referral to head or shoulder
 History of prolonged or unusual positioning of
neck
Differential diagnosis
•
Acute disc prolapse
•
Cervical spine injury
•
Drug reactions e.g. metoclopramide, antipsychotics
•
Cervical lymphadenopathy (infection/cancer)
•
Retropharyngeal abscess
•
Vertebral infection
•
Ocular disorders
•
Neurological with dystonia e.g. cva/encephalitis
Management
•
1-7 days
•
Recurrence is common
•
Analgesia
•
Gentle exercise
•
Heat/cold
•
Good posture
•
No collar
•
Beware of driving
Features of pain

Site - Where is the pain?

Onset - When/how did the pain start (e.g. sudden, gradual?)

Character - Describe the pain (e.g. dull ache, sharp stabbing)

Radiation - Does the pain move anywhere

Associations - Any symptoms/signs associated with the pain?

Timing - How has the pain changed over time?

Exacerbating/Relieving factors - Does anything worsen/relieve the
pain?

Severity - How bad is the pain on a scale of 1(mild) to 10 (worst ever).
Case Study 2
 32 year old man involved in RTA this morning
 Driver of vehicle
 Head on collision combined speed 50-60mph
 Seat belt
 Head restraints
 Air bag deployed
 Pins and needles in right hand
Cervical spine immobilisation
and XR
 Falls > 1 metre
 Altered mental status (GCS < 15)
 Neurological deficit (including subjective
symptoms)
 Drug or alcohol intoxication
 Spinal pain
 Extremity fracture
Is the spine clear?
•
GCS 15
•
Neurologically intact (including subjective
symptoms)
•
No distracting injuries
•
No neck pain or tenderness
•
FROM cervical spine
•
Best practice (BMJ Nov 2012)
Acute Whiplash
 Confirm accurate history for medico-legal
reasons
 Neck pain, head pain,
 Fatigue, dizziness, paraesthesiae, nausea, jaw
pain
 MANAGEMENT?
Management
 Reassurance about self-limiting
 Early return to normal activities
 Discourage rest and soft collars
 Outlook varies with culture, payment for health
services, compensation
 More pain, symptoms initial disability is assoc with
delay
Management
 Analgesia
 Physiotherapy
 Yellow flags – intervene early
 Correct erroneous beliefs
 CBT
 Pain clinic
Yellow flags (New Zealand Guidelines Group)
•
Belief that pain and activity harmful
•
Sickness behaviours like extended rest
•
Social withdrawal
•
Emotional problems e.g. depression anxiety and
stress
•
Work problems
Yellow flags (New Zealand Guidelines Group)
•
Problems with time off work
•
Compensation?
•
Overprotective family
•
Lack of support
•
Inappropriate expectations of treatment
Resist Chronicity?
 Resist prescriptions
 Resist investigations
 Encourage normality
 Diagnose co-morbidity (e.g. depression)
 Do not corroborate poor prognosis
 Continue education about behaviour / beliefs
 Pain clinic early?
So Far:
 Importance of history
 Torticollis
 Acute whiplash
 Yellow flags
 Now: anatomy, posture, movement testing
anatomy, posture, movement
testing
Red Flags
 New symptoms <20 or >55
 Weakness > 1 myotome or loss of sensation > 1
dermatome
 Intractable or increasing pain
Myelopathy
 Insidious progression
 Neuro symptoms e.g. gait, clumsy hands,
sex/bladder/bowel
 Neurological signs e.g. UMN in lower limbs or
LMN signs in upper limbs
Cancer infection or
inflammation
•
Malaise
•
Fever
•
Weight loss
•
Increasing, unremitting, sleep disturbing
•
History - inflamm arth, cancer, TB,
immunosuppression, AIDS
•
Lymphadenopathy
•
Exquisite local tenderness over a vertebral body
Severe trauma / skeletal injury
 History of violent trauma e.g. fall from height,
RTA, but watch for osteoporosis
 History of neck surgery
 Risk factors for osteoporosis e.g. menopause
early or steroids
Vascular insufficiency
 Dizziness and blackouts e.g. Sistine Chapel
 Drop attacks
Case Study 3
 45 year old man
 2 weeks of neck pain
 Works in warehouse – some IT some labour
 Worse at the end of the day
 Radiates down both arms
 Arms feel numb at times
Non – Specific neck pain
 2% GP consultations
 Prevalence in middle age, women > men
 Point prevalence of 8%
 Lifetime prevalence of about 50%
(clinical evidence 2008)
Non-specific neck pain
•
Varies with different activity – rest may aggravate OR rest may
relieve pain
•
Radiates on non-segmental distribution
•
May be sensory symptoms without signs
•
Varies with time
•
Related to
•
OR
poor posture
•
OR
overuse
•
OR
non of these
awkward movement
Examination of non-sp neck pain
•
Positional asymmetry – a change in the most
comfortable resting position
•
Unequal restriction in range of movement
(although this is common in degenerative
disease)
•
Tenderness in hypertonic muscles
•
Poorly localised tenderness
•
Localised areas of inc muscle tone? – nodules or
tender bands
Risk factors
• Workplace or workstation
• Duration of position
• Hand-arm vibration
• Twisting/bending of trunk
• Excessive use of pillows
Management < 4 weeks
 Identify risk factors
 Identify psychological factors
 Imaging not usually required
 Reassurance
 Encouragement of activity and normality
 One firm pillow in the hollow of the neck
 Analgesia
Management > 4 weeks
 As previously PLUS:
 Physiotherapy
 Address psychosocial factors
 ?occupational health
 Acupuncture
Management > 12 weeks
 As previously PLUS:
 Trial of amitriptyline or gabapentin/pregabalin
 Pain clinic ?
Case Study 4
 58 year old man – Scaffolder
 1 month of increasing discomfort in neck
 Radiation down left arm
 Shakes left hand when holding things
 Arm feels tight/numb
Cervical radiculopathy
Symptoms
 Usually unilateral
 Neck shoulder or arm in a dermatome
 Sensory symptoms
 Weakness
 Pain or no pain
 Nocturnal pain interfering with sleep
Symptoms
 Usually gradual but may be abrupt. Often a
combination
 Sensory more common than motor symptoms
 C5-T1 most commonly
DERMATOMES
 Neurology refresher…
Examination
 Asymmetry to help decompression of nerve root
 Reduced neck movements
 Spurling’s test
 Muscle weakness or sensory change
 Change in tendon reflexes
 Neural stretch tests
 Acute torticollis
 Acute whiplash
 Chronic whiplash
 Red flags
 Yellow flags
 Non-specific neck pain
 Cervical radiculopathy
Back Pain
Prevalence
 LBP affects 1/3 of UK population each year
 Only 20% of people with LBP consult GP
 MAINLY: non-specific and serious causes rare
Prognosis
 Difficult to prognosticate because of irregular course
of symptoms
 Risk factors for slower return to work:
 leg pain as well as back pain
 Repeated episodes
 Co-morbidities
 Manual work or lower socioeconomic class
 Longer duration off work
 Psychosocial factors
Definitions
 Non-specific low back pain
 Specific low back pain
 Mechanical back pain
 Inflammatory back pain
Non-Specific Low Back Pain
 pain, tension, soreness, or stiffness in the lower
back which cannot be attributed to a specific
cause.
 Sprains and strains included.
 best thought of as a symptom or complaint —
not as a disease or homogeneous condition.
 Non-specific low back pain is also called simple,
or uncomplicated, low back pain.
Inflammatory low back pain
 low back pain and stiffness aggravated by rest
or sleep
 often waking the person in the second half of
the night.
 It lasts >30 minutes after getting up
 relieved by physical activity & NSAID.
 typical of ankylosing spondylitis and other
rheumatic conditions.
Mechanical LBP
 varies with posture or movement.
 E.G.: aggravated by standing and relieved by
sitting or lying; in others: vice versa.
 Mechanical low back pain is typical of non-
specific low back pain, and specific causes such
as sciatica, vertebral fracture, and facet joint
injury.
 Importance is exclusion of inflammatory back
pain.
Sarah….
Non-specific
low back
pain
Diagnosis
 Rule out serious pathology
Cauda
Equina
Red flags for cauda equina
 Saddle anaesthesia or paraesthesia
 Recent onset bladder dysfunction
 Recent onset faecal incontinence
 Perianal sensory loss
 Unexpected laxity anal sphincter
 Severe OR progressive neuro deficit
Red flags for fracture
 From medical history:
 Sudden onset of severe central pain relieved by
lying down.
 Major trauma e.g. RTA, fall from a height. Minor
trauma, or even just strenuous lifting, in people
with osteoporosis.
 From physical examination:
 Structural deformity of the spine (such as a step
from one vertebra to an adjacent vertebra)
Red flags for cancer or infection
 older than 50 years, or younger than 20 years
 History of cancer.
 Recent bacterial infection (for example urinary
tract infection).
 Intravenous drug misuse.
 Immune suppression.
Red flags for cancer or infection
 Constitutional symptoms, such as fever, chills, or
unexplained weight loss.
 Pain that remains when lying down,
 aching night-time pain that disturbs sleep,
 thoracic pain (which could also be caused by
an aortic aneurysm).
 O/E: Structural deformity of the spine (such as
scoliosis).
Ruled out serious pathology…
Check pain
 From back
 Is mechanical
 Is not inflammatory (?ESR, CRP)
Check for long term prognosis

Misunderstanding of the cause of back pain.

The belief that pain and activity are harmful.

Sickness behaviours, such as extended rest.

Overprotective family.

Social withdrawal, lack of support.

Emotional problems such as low or negative mood, depression, anxiety,
or feeling under stress.

Problems with claims for compensation or applications for social
benefits.

Inappropriate expectations of treatment, such as low expectations of
active participation in treatment.
Management
 positive attitude
 realistic expectations.
 Avoid ‘threatening’ language
 'the normal ageing process of the spine' rather
than 'wear and tear', 'crumbling discs', or
'damage to disc or joint'.
Information:
 real physical cause
 disturbance of function, not by serious structural
damage.
 Settles in most people but can recur repeatedly
 Analgesia, mobilise and back to work ASAP
 normal activities should be paced
 The aim is to do a little more each day.
Information
 Care with lifting and twisting
 Cushion between knees when sleeping on side
 No need for complete resolution before work
 Work can help with distraction
 Analgesia (paracet/NSAID/opioid)
 ?use of diazepam x 5/7
 Expect resolution <6 weeks
Chronic (>6 weeks)
 Structured exercise programme
 Manual therapy
 Acupuncture
Poor response?
 Check for red flags
 Check for yellow flags
 Consider other conditions
 Consider referral to pain mgt clinic
 If severe, consider specialist spinal surgical
service -> ?fusion
Not recommended for chronic
low back pain
 Non-specific
 Less than a year
 Should not be treated or referred with:
Not recommended for chronic low
back pain
 Alexander technique (exercise likely to be more
cost-effective) not available on NHS
 Massage
 Percutaneous electrical nerve stimulation (PENS)
 Transcutaneous electrical nerve stimulation
(TENS)
 SSRI
 Injection of substances into the back
Not recommended for chronic low
back pain
 Laser therapy
 Interferential therapy
 Therapeutic ultrasound
 Lumbar supports
 Traction
 Radiofrequency electrothermal therapy
 Percutaneous intradiscal radiofrequency
thermocoagulation (PIRFT)
 Neuroreflexive therapy
Opioids in Back pain
 On the increase
 Some estimates 30% of LBP last >1y
 Cochrane review
Use of opioids
 4 studies
 3 compared tramadol to placebo
 900 patients in total…
 There still remains little evidence in the
medical literature to address the
concerns of physicians and patients
regarding the effect of opioids on pain
intensity, improved function and risk of
drug abuse.
Examination
 Dermatomes
 Myotomes
 Neural tension signs
Examination
 Fingertip to floor
 Schober – S1 and 10cm above (9-15cm)
 Hoover’s test – hand under contralat. foot
 Waddell’s signs
 Tenderness, axial loading, distraction (SLR),
regional disturbances, over-reaction

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