From the Guidelines
When approaching a patient with cervical pain, begin with a thorough history by asking about the pain's onset, duration, location, radiation, character, aggravating and relieving factors, and associated symptoms like headache, dizziness, or arm numbness, as recommended by the American College of Radiology 1. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain, and inquire about trauma history, occupational factors, previous neck problems, and red flag symptoms such as fever, weight loss, or neurological deficits. For the examination, observe the patient's posture and neck position, then assess range of motion in all directions (flexion, extension, lateral rotation, and lateral flexion), noting any limitations or pain, as suggested by the American College of Physicians and the American Pain Society 1. Palpate the cervical spine and surrounding muscles for tenderness, spasm, or step-offs, and perform a neurological examination including motor strength, sensory testing, deep tendon reflexes, and pathological reflexes like Hoffman's sign. Special tests such as the Spurling test (for radiculopathy), distraction test, and compression test can help identify specific pathologies, and assess for vascular insufficiency with the Adson's test, as recommended by the American College of Radiology 1. Complete the examination by checking shoulder movement and evaluating for referred pain patterns, which helps differentiate between mechanical neck pain, radiculopathy, myelopathy, and serious pathologies requiring urgent intervention, allowing for appropriate management decisions, as suggested by the American College of Radiology 1. Key points to consider in the history and examination of a patient with cervical pain include:
- Onset, duration, location, radiation, character, aggravating and relieving factors, and associated symptoms
- Trauma history, occupational factors, previous neck problems, and red flag symptoms
- Range of motion, palpation of the cervical spine and surrounding muscles, and neurological examination
- Special tests such as the Spurling test, distraction test, and compression test
- Assessment for vascular insufficiency with the Adson's test and evaluation of referred pain patterns.
From the Research
Approach to History and Examination
The approach to history and examination of a patient with cervical (neck) pain involves a biopsychosocial approach, considering the patient's physical, psychological, and social factors 2. A comprehensive assessment is essential, including a thorough history and physical examination.
Key Components of Assessment
- A general structured overview of assessment and management is outlined, focusing on early comprehensive assessment and individualized management planning 2
- History and physical examination are crucial in diagnosing cervical facet-related pain, with diagnostic blocks used to confirm the diagnosis 3
- Imaging techniques, such as MRI or CT scans, may be used for procedure planning, but have limited value in diagnosing cervical facet pain 3
- A comprehensive history and physical examination are essential in investigating common cervical and thoracic conditions, including cervicogenic headache 4
Diagnostic Tools and Techniques
- Diagnostic blocks, such as local anesthetic blocks, can be used to diagnose cervical facet-related pain 3
- Ultrasound imaging and guidance can be used to precisely localize myofascial trigger points and guide procedures for cervical myofascial pain 5
- Fluoroscopy-guided cervical interlaminar epidural steroid injection (CIESI) can be an effective treatment for neck pain and cervical radiculopathy, with diagnosis and outcome predictors, such as herniated disc or spinal stenosis, influencing treatment effectiveness 6
Management and Treatment
- Conservative management, including exercise therapy, is the first line of treatment for cervical facet-related pain 3
- Radiofrequency treatment of the medial branches can be considered for patients who do not respond to conservative management, often resulting in adequate pain relief 3
- CIESI can be a safe and effective means of treating patients with neck pain and cervical radiculopathy, with the cause of pain being a significant outcome predictor 6