Neck Pain Presentations Overview

Neck Pain Presentations

• Neck Pain with Mobility Deficits: Pain may be unilateral or bilateral, referred (not radiating), localized, and present at end-range of motion. Accessory movements may be hypomobile. Pain can be triggered by unguarded or awkward movement. Imaging might show abnormalities, but symptoms may be absent. Common underlying causes include spondylosis (facet joint arthritis) and cervicalgia (minor neck strain).
• Neck Pain with Headaches (Cervicogenic Headache): Women are four times more likely to experience this. Mean age is 42.9. Neck pain is a common complaint in headache sufferers (70%). CGH accounts for 14-18% of chronic headaches and 15-20% of recurrent headaches.
  • Pathophysiology: Impairments in the cervical spine cause the headache.
  • Signs & Symptoms: Primarily unilateral headache (no side shift), moderate-severe, non-throbbing, non-lancinating pain. Pain is localized to occipital, frontal, temporal, or orbital regions. Neck stiffness and restricted active and passive range of motion (AROM, PROM) are common.
  • Triggers: Neck movement, posture, limited ROM, and pressure on C0-C3.
  • Differential Diagnosis & Red Flags: Upper cervical instability, cervical myelopathy, and cervical arterial dissection should be considered. Red flags include sudden onset severe headache, persistently unilateral headaches, headaches waking the patient, stiff neck, systemic symptoms (fever, weight loss), and focal neurologic signs.
• Neck Pain with Radiating Pain (Cervical Radiculopathy): This is characterized by nerve compression and inflammation in the cervical spine, often affecting C6 and C7 nerve roots.
  • Pathophysiology: A combination of compression and inflammation of spinal nerves.
  • Patient Presentation: Most common in the 50s, symptoms usually emerge insidiously or suddenly, often preceded by episodic neck pain. Slight lateral flexion away from the affected side is common.
  • Signs & Symptoms: Neck pain progressing to arm pain, scapular pain, sensory changes (tingling/numbness), diminished or absent reflexes, and muscle weakness typically in a myotomal pattern.
  • Important Note: Symptoms rarely follow dermatomal patterns, and tests may yield false positives. Be aware of Bakody's sign (specifically the shoulder abduction test).
  • Typical Prognosis: Acute episodes usually improve within 6-8 weeks, with continuous improvement over 4-6 months. Full recovery can take 24-36 months. Recurrence is possible in about 1 in 4 patients.
• Lower Motor Neuron Lesion Presentation: Flaccidity, hypo-reflexia, muscle atrophy, loss of sensation, lack of pathological reflexes (Babinski, inverted supinator sign, clonus), presence of superficial reflexes, and potential for fasciculations/fibrillations. Commonly occurs between the ages of 30 and 50.
• Cervical Discogenic Disorders (Somatic Referral): This condition may present as pain in the mid-thoracic or periscapular areas (Cloward's Points). Symptoms can be vague or localized, possibly with a denial of neck pain. Stiffness is a key element to ask about. No myotomal, dermatomal, or reflex changes occur. Aggravating factors include sustained flexed posture, looking up, turning head toward the involved side, and morning stiffness that worsens as day progresses.
• Whiplash: Often triggered by trauma, affecting C5-C6, often causing muscle strain (SCM), facet joint issues, ligament sprain, nerve involvement, and disk injury.
  • Enabling factors: Trauma.
  • Presentation:
    • Sensorimotor: Increased errors in head positioning, balance problems, impaired eye movement, and possible dizziness.
    • Sensory: Hypersensitivity (widespread pain) and inexplicable pain patterns.
    • Motor: Most commonly, loss of cervical anterior-posterior range of motion (AROM).
    • Psychological: Post-traumatic stress symptoms (re-experiencing, avoidance, hyperarousal) can be present.
  • Poorer Outcomes: High pain ratings , high NDI scores (>14.5/50) correlates to worse outcomes.

Dizziness and Vertigo

• Dizziness: Lightheadedness, imbalance, giddiness, or unsteadiness
• Vertigo: Feeling of movement when stationary.
• Cervicogenic Dizziness (CGD): A neck proprioception disorder often with musculoskeletal (85%), vestibular (involved 85% of vertigo patients), cardiovascular, or neurological causes.
  • Etiology: Unknown but potentially correlated with whiplash, chronic inflammation, and spondylosis.
  • Diagnosis: Rule out: BPPV, Meniere's Disease, tumor, trauma, Chiari malformation, Vertebral Basilar Artery Insufficiency, and other pertinent red flags.
• Benign Paroxysmal Positional Vertigo (BPPV): Otoconia (calcium carbonate crystals) dislodge from the utricle, causing vertigo and nystagmus triggered by changes in head position
• Ménière's Disease: Chronic vestibular disorder with symptoms including aural fullness, vertigo, and hearing loss. CGD does not have these symptoms.
• Red Flag Screening: Vitals, cranial nerve exam, and testing for myelopathy, instability, and cardiac considerations as necessary.

Hypermobility

• Hypermobility: Potential to develop insidiously, associated with Ehlers-Danlos syndrome, or trauma. Patients presenting with this complaint may frequently change positions and report sensations of a heavy head, weariness, or frequent manipulation with minimal lasting change.
• Cervical Myelopathy: A concern with hypermobility.