Neck pain and stiffness

Probability diagnosis

Vertebral dysfunction, incl. acute torticollis

Traumatic ‘strain’ or ‘sprain’, incl. ‘whiplash’

Cervical spondylosis

Serious disorders not to be missed

Cardiovascular:

• angina

• subarachnoid haemorrhage

• arterial dissection

Neoplasia/cancer:

• primary tumour

• metastasis

• Pancoast tumour

Infection:

• osteomyelitis

• meningitis

• atypical infection, e.g. tetanus, leptospirosis

Vertebral fractures or dislocation

Pitfalls (often missed)

Disc prolapse

Myelopathy

Cervical lymphadenitis

Fibromyalgia syndrome

Outlet compression syndrome (e.g. cervical rib)

Polymyalgia rheumatica

Ankylosing spondylitis

Rheumatoid arthritis

Oesophageal foreign bodies and tumours

Paget disease

Masquerades checklist

Depression

Thyroid disorder (thyroiditis)

Spinal dysfunction

Is the patient trying to tell me something?

Highly probable. Stress and adverse occupational factors relevant.

Key history

General pain analysis, especially the nature of onset, its site and radiation, and associated features. Past history of neck pain and trauma. Check for presence of radicular pain in arm and paraesthesia or numbness, and for weakness in the arm.

Key examination

• Follow the process for examination of any joint or complex of joints: look, feel, move, measure, test function, look elsewhere and X-ray

• Three objectives of the examination: reproduce the patient’s symptoms, identify the level of the lesion or lesions, determine the cause (if possible)

• Perform a neurological examination if radicular pain, weakness or paraesthesia is present in the arm

Key investigations

Consider:

• FBE

• ESR

• rheumatoid arthritis factors

• radiology can include several modalities but MRI is the investigation of choice for radiculopathy, myelopathy, suspected spinal infection and tumours.

Imaging should be selected conservatively and plain X-ray is not indicated in the absence of red flags and major trauma.

Diagnostic tips

• The commonest cause of neck pain is idiopathic dysfunction of the facet joints without a history of injury.

• Strains, sprains and microfractures of the facet joints, especially after a whiplash injury, are difficult to detect and are often overlooked as a cause of persistent pain.

• ‘One disc—one nerve root’ is a working rule for the cervical spine.