E4: Differential Diagnosis of Neck Pain

Question 1

What are some congenital etiologies of torticollis?

Answer 1

Trauma at birth
Klippel-Feil syndrome
Basilar impression
Atlanto-occipital fusion
Pterygium colli (web neck)
Odontoid abnormalities

Question 2

What is Klippel Feil syndrome?

Answer 2

Cervical spine anomaly consisting of multiple fused vertebrae, possible hemivertebrae or other anomalies

Question 3

On physical exam, what signals Klippel Feil syndrome?

Answer 3

Segmental motion testing demonstrates total motion loss, not just restriction.

Question 4

What are some inflammatory etiologies of torticollis?

Answer 4

Lymphadenitis in the neck
Tuberculosis
Typhoid
Rheumatoid arthritis *most common - causes spontaneous Atlanto-axial rotatory subluxation

Question 5

How does rheumatoid arthritis induce torticollis?

Answer 5

It erodes away the transverse odontoid ligament with subluxation of the dens posteriorly into the spinal canal

Question 6

If a patient presents with neck pain and has RA elsewhere in the body, what should be done before taking a manipulative approach?

Answer 6

Perform flexion/extension films of the odontoid

Question 7

What are some neurologic etiologies of torticollis?

Answer 7

Ocular dysfunction
Syringomyelia
Spinal cord tumor
Cerebellar tumor
Bulbar palsies
Spasmodic torticollis

Question 8

What is syringomyelia?

Answer 8

Central cavitation (dilation) of the spinal cord

Question 9

When do symptoms of syringomyelia typically appear?

Answer 9

Second/third decade of life

Question 10

Which demographic is more affected by syringomyelia?

Answer 10

Men

M:F - 7:3

Question 11

What is the calling card of syringomyelia?

Answer 11

Awkwardness/weakness in the extremities
“Claw hand”
Radicular pain is UNUSUAL

Question 12

What are the red flags for possible infection with neck pain?

Answer 12

Age: >50 years or <20 years
Fever or chills
Pain worse supine
Recent UTI
IV drug abuse
Immune suppression

Question 13

What are common infectious causes of neck pain?

Answer 13

Sinusitis
Cervical adenitis
Parotitis
Lyme arthritis
Osteomyelitis

Question 14

What are the red flags for possible tumor with neck pain?

Answer 14

Age: >50 years or under <20 years
Unexplained weight loss
Pain worse when supine
Severe nocturnal pain

**NO fever

Question 15

What Beighton score do most people with Ehlers-Danlos have?

Answer 15

7

Question 16

What is the most common sub-type of Ehlers Danlos?

Answer 16

Type III - Hypermobility Type

1 in 10-15,000 people

Question 17

What are hypermobile Ehlers Danlos patients prone to?

Answer 17

Chronic joint pain

Question 18

What is Classical Type Ehlers Danlos and what are the symptoms?

Answer 18

Types I and II

Highly elastic, velvety skin
Fragile skin that bruises and tears easily
Slow and poor wound healing leading to scarring
Non-cancerous fibrous growths on pressure areas such as elbows and knees

Question 19

What is a major implication of Type IV Ehlers Danlos?

Answer 19

Type IV = Vascular Type

Fragile blood vessels and organs are prone to rupture

Question 20

Percussive pain is present with which conditions?

Answer 20

Fracture
Tumor
Osteomyelitis
Infectious discitis
Facet joint synovitis

Question 21

Neck pain that radiates into shoulder, arm, forearm, wrist, or hand indicates which condition?

Answer 21

Herniated cervical disc

Question 22

This technique will make the symptoms of any space-occupying lesion in the spinal canal worse.

Answer 22

Valsalva maneuver

Question 23

What aspects of patient’s history would indicate herniated cervical disc?

Answer 23

Pain that radiates into a dermatomal distribution

Numbness/paresthesias in a dermatomal distribution

Question 24

PE findings that indicate herniated cervical disc

Answer 24

Abnormal head carriage

Loss or reversal of cervical lordosis

Question 25

What is Lhermitte sign?

Answer 25

Electrical shock paresthesia down back, arms, or legs with flexion of the neck

Question 26

When does Lhermitte sign occur?

Answer 26

With any cause of spinal cord compression | Occurs with many causes of spinal cord inflammation

Question 27

Nerve root compression results in reflex _____. Spinal cord compression results in reflex _____.

Answer 27

Loss | Abnormality

Question 28

Hoffman test

Answer 28

Support the middle finger and then flick it | Positive sign: thumb and pointer finger move

Question 29

Hypoplastic dens may be present in which demographic?

Answer 29

Dwarfism | Down Syndrome

Question 30

Syringomyelia patients typically do not have _____.

Answer 30

Pain

Question 31

If patient has rheumatoid arthritis elsewhere in the body, what should you do before a manipulative approach?

Answer 31

Perform extension/flexion films of the odontoid to determine stability

Question 32

Which mechanical abnormality is most common in people over 50?

Answer 32

Kyphosis with anterior head carriage

Question 33

Where is point tenderness for Scapulo-Costal syndrome?

Answer 33

Insertion of the levator scapulae muscle

Question 34

What movement exacerbates Scapulo-Costal syndrome?

Answer 34

Elevation and adduction of the humerus

Question 35

Using a brace for localized hypermobility treatment also requires the patient to do what?

Answer 35

Exercise. Lack of exercise will make them more unstable.

Question 36

Possible treatment for localized hypermobility

Answer 36

``` OMT Exercise Bracing Prolotherapy Surgical fusion ```

Question 37

Complications of Ehlers-Danlos

Answer 37

``` Prominent scarring Difficulty with surgical wounds healing Chronic joint pain Rupture....of everything Premature aging with sun exposure Early onset arthritis ```

Question 38

Ehlers-Danlos treatment

Answer 38

OMT (same as for benign hypermobility) Stabilization exercises Vitamin C

Question 39

What is Chvostek sign?

Answer 39

Facial muscles involuntarily contract when the facial nerve is percussed. Sign of hypocalcemia.

Question 40

Most common failed surgeries that cause neck pain

Answer 40

Cervical spine Dental Ophthalmologic Otolarynologic

Question 41

Pain referred FROM the head and neck

Answer 41

``` Breast pain (C5/C6 nerve root) Precordial pain (C5/C6 nerve root) --> pain in front of the heart Facial pain (trigeminal neuralgia) ```

Question 42

Conditions that refer pain TO the head and neck

Answer 42

``` Cardiac pain Complex regional pain syndrome (Reflex Sympathetic Dystrophy Syndrome) (Barre-Leiou syndrome) Dental pain Myofascial trigger points Occipital neuralgia Ocular pain ```