Chronic Neck Pain: Generators, Clinical Examination, MRI Findings, and Differential Diagnosis

The following article is part of conference coverage from the PAINWeek 2018 conference in Las Vegas, Nevada. Clinical Pain Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in pain medicine. Check back for the latest news from PAINWeek 2018.

LAS VEGAS — In a presentation given during the 2018 PAINWeek conference, held September 4-8, David M Glick, DC, DAIPM, managing director of PainRx, presented an overview of direct and indirect generators of neck pain, and exposed some of the deficiencies of regional examinations in the differential diagnosis of this condition.

Dr Glick started by dispelling myths surrounding neck pain. “It is a symptom, not a pathology,” he noted, stressing that neck pain does not always stem from disk herniation, and that no one treatment is effective for all kinds of neck pain. Failure to adequately diagnose — and treat — neck pain often results in chronicization of the condition. As not every clinician is trained to diagnose the causes underlying chronic neck pain, adequate “diagnostic triage” is essential in order to achieve successful clinical outcomes, Dr Glick said. Healthcare practitioners should obtain a detailed clinical history of patients and perform a thorough clinical examination. Experience with similar cases may also improve treatment outcomes.

The presence of disk protrusions in the lumbar spine on magnetic resonance imaging (MRI) in patients with no back pain is thought to be highly prevalent and therefore may be coincidental, but may not be responsible for neck pain, noted Dr Glick. In a 2016 retrospective study of 3107 lumbar spine MRIs, it was estimated that only 41.3% of imaging findings were likely to have clinical significance and 58.3% were regarded as clinically negative.²

Chronic pain in the neck or in the upper extremities may have a neuropathic origin (eg, radiculopathy, neuromuscular disorder) or may arise from arthropathies, tendinopathies, or myopathies. It may also have a vascular or autonomic origin.

Dr Glick presented a “typical scenario” of a patient with chronic neck pain. The patient presents with right-sided neck pain, is complaining of suboccipital headaches, and has a history of tingling in the third to fifth digit of his right hand. No evidence of canal or foraminal stenosis is visible on MRI, with only minimal degenerative joint disease findings at levels C3 to C6. The patient has been treated with physical therapy, trigger point injections, epidural steroid injections, facet injections (ie, radiofrequency ablation and nerve blocks at the medial branch), none of which provided any long-term pain relief.

Upon clinical examination, the patient reported tenderness along the nuchal line, hypertonicity of the trapezius, local multifidus tenderness over the right C3/C4 facet joint, and pain over the second costovertebral joint on the right side. The rest of the examination, including deep tendon reflexes, motor and sensory function, and cervical range of motion, were all normal.

Based on these findings, the revised clinical impression is that the headaches may be a result of tendonitis-enthesitis of the splenius cervicis, splenius capitis, and trapezius muscles, and that the rib arthropathy may be contributing to a mild radiculitis at C8. In addition, an irritation of the right C3/C4 facet may be playing a role in the trapezius tendonitis/enthesitis. A new course of treatment might include topical diclofenac in the suboccipital region, manipulation for the rib arthropathy, intra-articular facet injections at the C3/C4 level on the right side, pain education, and a biopsychosocial intervention to teach the patient some pain-coping skills. In addition, previously prescribed medications should be discontinued.

Dr Glick noted that clinical examination should include evaluation of the hand, elbow, shoulder, and neck to eliminate the risk for overlooking complicating or underlying pathology.

Negative test results should not take precedence over positive clinical findings, noted Dr Glick. A patient’s neck pain may result from more than one cause, and clinicians should “look at the patient, not only a body part, giving careful thought to anatomy and physiology (or pathophysiology),” he concluded.

References

1. Glick DM. Neck and upper extremities pain syndromes. Presented at: PAINWeek 2018; September 4-8, 2018; Las Vegas, Nevada. Presentation CSP-02.
2. Yu L, Wang X, Lin X, Wang Y. The use of lumbar spine magnetic resonance imaging in Eastern China: Appropriateness and related factors. PLoS ONE. 2016;11(1):e01463.

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