SESSION J3. What a Pain in the Neck! Clinical Pearls for Neck Pain Christopher J. Standaert, MD

37th Annual Advanced Practice in Primary and Acute Care Conference: October 9-11, 2014 2:45 SESSION J3 What a Pain in the Neck! Clinical Pearls for ...
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37th Annual Advanced Practice in Primary and Acute Care Conference: October 9-11, 2014

2:45

SESSION J3 What a Pain in the Neck! Clinical Pearls for Neck Pain Christopher J. Standaert, MD

Session Description: Neck pain is a very common clinical complaint, and it can be challenging to effectively diagnose and treat patients with neck pain. This session will help clinicians to understand important etiologic factors in neck pain, various treatment modalities, and patient factors that are critical in optimizing outcomes for treatment. Specific approaches, language, and conceptual models will be discussed. Learning Objectives: Following my presentation, participants will be able to: 1. Discuss specific conditions or injuries that are commonly associated with neck pain. 2. Identify critical factors in the evaluation of patients with neck pain. 3. Articulate important concepts in treatment, particularly as related to clinical outcomes.

S E S S I O N J3

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Overview Making sense of Neck Pain: “What a Pain in the Neck!”

Christopher J. Standaert, MD Department of Rehabilitation Medicine UW Sports and Spine Physicians Harborview Medical Center

Cervical Spine • 7 vertebrae • Spinal cord • Structurally unique – – – –

A-O junction C1-2 Uncinate processes Disc structure

Anatomy • Neural elements – Spinal cord – Nerve roots

• Anatomy & Biomechanics • Understanding neck pain • How to assess patients • Treatment • What do I say to patients?

Cervical Spine • Cervical vertebrae – Mobility – Facet joints – Uncinate processes • Vertebrae contact one another • Frequently spur • Narrow foramen

Cervical Spine • Cervical discs – Crescentic, thick anterior anulus – Thin posterior anulus • Posterior longitudinal ligament

– Vulnerable posterolaterally

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Cervical Spine • 7 vertebrae • Spinal cord • Structurally unique – – – –

A-O junction C1-2 Uncinate processes Disc structure

Cervical Spine • Cervical vertebrae – Mobility – Facet joints – Uncinate processes • Vertebrae contact one another • Frequently spur • Narrow foramen

Anatomy • Neural elements – Spinal cord – Nerve roots

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Cervical Spine

Epidemiology

• Basic motions

• Neck pain – Up to 71% lifetime incidence – 10% with chronic neck pain

– Flexion • Compress anterior structures • Tension posterior structures

• Neck/shoulder/arm pain

– Extension

– Prevalence 25% females & 15% males

• Compress posterior structures • Tension anterior ligaments • Narrow spinal canal

• In Sweden • Leijon et al Spine 2009

Acute Spine Pain

Understanding Pain

• Anything with a nerve supply can hurt – Musculotendinous units – Ligaments – Disc – Facet joint – Nerve root – Vertebrae – Others

– Bogduk, 2003

Understanding Pain • Pain referral patterns • Dermatomal • Myotomal • Sclerotomal • Segmentally based

C6 Ant

• It is not the structure that determines the pattern of pain stemming from it: rather, the pattern of pain is determined by the nerve supply of the structure.

Understanding Pain Post

• Cervical discogenic pain – Cloward, 1959

• Felt along scapula

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Understanding Pain • Cervical discogenic pain

Understanding Pain • Cervical zygapophyseal joints (facets)

– Cloward, 1959

– 49% of chronic neck pain after whiplash – 50% of headache (C2/3 joint) after whiplash

• Felt along scapula • Level varies by level of the disc

– Lord, et al, 1996

Understanding Pain Cervical

Lumbar

• Facet joint more common cause of axial pain than disc • Radiculopathy more commonly related to uncovertebral spur/ bone • 10% of epidural injections • Spinal cord, arteries, etc complicate surgical approaches to spine

• Disc is more common source of axial pain than joint • Radiculopathy more commonly caused by disc protrusion • 90% of epidural injections • Spinal canal relatively accessible to surgical approaches

Understanding Pain • Acute pain – Pain associated with tissue injury – Acute inflammatory response – Withdrawal from exacerbating activities helpful – Passive modalities can be helpful

• Chronic pain – Pain occurs without tissue injury – Acute inflammatory response often resolved – Withdrawal is maladaptive – Over-reliance on passive or interventional care is maladaptive

Understanding Pain • Pain is a sensory and emotional experience • Direct nociception • Cortical modulation • Psychological factors • Acute pain is distinct from chronic pain • Pain is distinct from suffering

Understanding Pain • Chronic pain – Physiological changes – Strong role of psychological factors – Outcomes for interventions are worse

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Chronic Pain Pain is a complex perception- an experience- not a thing that can be surgically excised or pharmacologically “killed.” – Sinclair 2003

Assessment • Rule out bad things • Establish diagnosis • Understand scope of the problem – Pain – Disability – Psychosocial barriers

• Initiate treatment plan

Assessment • Red Flags

Assessment • Fracture

– Fracture – Tumor or infection – Significant neurologic injury • Radiculopathy • Myelopathy • Cauda equina injury (Lumbar) • AHCPR guidelines

Assessment • Myelopathy – Loss of dexterity – Balance difficulty – Weakness – Bowel/ bladder fxn – Paresthesias into both arms • CTS vs spinal cord

– Immediate pain after trauma – Focal tenderness – Reduced ROM – Neurologic involvement – Altered consciousness

Assessment • Infection or tumor – Age >50 or