Accupational History

Jobs requiring hyperextension of neck for overhead work are prone for occipital neuralgia and
cervicogenic headache due to upper cervical spine involvement, where as job requiring prolonged
neck flexion such as computer work are prone for interspinous ligament sprain and lower cervical
spine involvement.
Family History
Various inflammatory and non-inflammatory arthritis such as rheumatoid arthritis, ankylosing
spondyitis, Reiters syndrome and psoriatic arthritis runs in a family and also tumors like
schwannoma, neurofibromas compressing cervical cord seen in familial neurofibromatosis type 1.
Family history of diabetes, hypothyroidism we help to identify diabetic neuropathy and widespread
pain.
Review of other Systems
For diagnosing referred pain from heart, lungs, abdomen, history regarding these system
involvement must be taken thoroughly. Angina can lead to referred neck pain with breathlessness on
exertion, dysarrhythmias. In C6-7 lesion pain and tenderness may be present and the scapular region
or over precordium know as pseudoangina . A pressure sensation is felt in the chest, which increases
with exercise, radiates down the arm, is aggravated by neck movement, and may be associated with
torticollis or muscle spasmin the neck. Differentiation of heart disease from symtoms associated
with C6-7 dysfunction is made on the basis of muscle weakness, fasciculations and sensory or reflex
changes. Pancoasts tumor is a neoplastic process of the apical portion of the lung that can couse a
mass effect on the caudad cervical nerve roots. In these patients respiratory symtoms like chronic
cough, hemoptosis or breathlessness will be present. Also respiratory infections can lead to cervical
lymphadenopathy causing neck pain. Diaphragmatic irritation due to peritonitis due to infection or
abdominal carcinoma will lead te reffered pain to shoulder and neck.
Past Trauma and Surgical History
History of accident with whiplash injury due to hyperextension followed by hyperflexion is
significant as these injury in acute cases should be carefully evaluated for unstable fractures and cor
comperssio. Mostly there is myofascial pain which will recover gradually. The prevalence of
cervical facetogenic pain is high in the whiplash population. pas history of trama or nerve injury
with pain more than inciting injury along with sympathetic and autonomic changes, CRPS can be
present. Past cervical spine surgery, facet joints and disc above and below fixation are more prone
for arthropathy and degeneration due to sifthing of load.
EXAMINATION
Clinical axamination related to neck pain starts as soon as patient enters the room.
Gait
It is a normal when neck pain is due to local phatology not involving cord. In cervical myelopathy,
trendelenburg gait, bilateral spastic, ataxic of spastic-ataxic gait can be present.
Body Habitus
Cancer patient wll be cachexic. Patient with chronic infection will bethin built.

Higher Functions
Mood and effect are altered due to chonic pain and help us to know impact of pain on daily reutine
quality of life. Cognition is impaired in cancer, vascul dissection and hemodynamically unstable
patients, inspection
Skin
Skin over neck and upper limb is inspected for post-herpetic vesicular scaring which will be
dermatomally distributed and do not cross midline in cases of post-herpetic neuralgia. Psoriatic skin
eruptions can be seen in psoriatic arthropthy. Signs of inflammation like erythema, swelling, redness
can be present in local pathologies of neck.
Head and Neck Posture
Patient with neck pain tries to stabilize joint by surrounding muscle contraction to avoid movement
aggravating pain. Observe the retention or loss of cervical lordosis, the patient may be splinting the
neck with the head turned away from the injured muscle. The posturing of the neck is termed
torticollis. The head is turned away from the side of the involved strenocleidomastoid.
Shoulder Symmetry
In case shoulders pathologies or neck muscles contrction in myofascial pain, shoulder joints will be
drooped or pulled upward
Muscle wasting
Gross muscle wasting can be seen on inpection suggestive of motor nerve fibre involvement like
brachial plexopthy. It will be present in both upper and lower limb in case on myelopathy.
Palpation
It help s to locate exact pain generators beliciting local tenderness. Axial cervical spinous tenderness
may be present in internal disc disruption, bilateral facet joint arthropathy where as interspinous
tenderness in case of interspinous ligament in sprain. Paramedic pain may be due to facet joint,
myofasce or local infecive source like lymp nod Table 5.4 shows various structures to be palpated
anterioly and posteorioly.
Range of Motion
It may reveal pain or limitations in flexionextension, lateral bending, and rotation. Neck flextion
occurs with 50% of the motion occurring at the occiput-C1 joint and the remaining 50% distributed
over C2-7. If the patient is unable to place the chin on the chest, the interval should be measured.
One fingers width shows a limitation of 10 degrees; three finger widths indicate a 30-degree
limitation in flexion. Backward neck extension, the distance between the base of the occipt and T1
spinous procces should be measured. Lateral flexion should allow the ear to touch the shoulder with
motion being shared across all cervical. Vertebrae. On rotation, the chin should touch the shoulder
with 50% of rotation occurring at C1-2 and the remaining 50%distributed in the sub axial between
C3-7. there is a natural decrease in range of motion with age, even and healty individuals. Range of
motion tets the ligaments, capsule, and fascia, and this range of motion is reduced in the presence of
cervical spinal muscular spasm or pain. Patients with degenerative changes of the cervical spine
have pain with decreased range of motion of the cervical spine. The most common findings

secondary to changes in the cervical spine articulations are ( in order ) : restriction of movement
with or without pain, pain on movement, and local tenderness. Lateral flexion is the earliest and
most impaired movement in degenerative diseases with rotation first impaired in rheumatoid arthritis
owing to involvement of the odontoig peg. A uniformly stiff neck may be caused by diffuse
idiopathic skeletal hyperostosis, which is present in a quiter of elderly petients, but also may be due
to ankylosing spondylitis or recent trauma to the neck. If articular sign are found, th examiner must
evaluate the entire vertebral column and peripheral joint for evidence of further arthritis and search
for extra-articular manifestations. Cause of decreased range of motion of the cervical spine include
joint locking and biny ankylosis from degenerative changes or arthritis, fibrous contracture, muscle
spasm, splinting over painful joints, and nerve root or spinal cord compression or irritation.
Special Test and Signs
This test changes the diameters of the neural foramen, increasing or decreasing the symptoms.
a. Sprulings maneuver (Fig. 5.1) : passive lateral flextion and compression of head.
Positive test is reproduction of radicular symptoms distant from nesk. It also increase
pressure on the cervical facet joints and may intensify facet mediate pain.
b. Shoulder abduction (relief) sign (Fid. 5.2) : Activ abduction of symptomatic arm,
placing patients hand on head. Positive test is relief or reduction of ipsilateral cervical
redicular symptoms.
c. Neck Distraction test (Fig . 5.3) : Examiner grasps patients head under occiput and chin
applies axia traction force for 30 to 60 seconds. Positive test relief for reduction of
cervical radicular symptomps. increased pain with this maneuver may be due to
inflammatory or degenerative disease, or muscle or ligaentous pathologhy.
d. Valsalva test (Fig .5.4) : this is test ferformed by having for patient place their thumb in
their mouth and below, as if to push the tumb out of their mouth. This maneuver increases
the intraspinal pressure and may reveal the presence of spaceoccupying lesons of the
cervical spine such as large intervertebral disk herniations, tumors, and stenosis due to
spondylosis or osteophytes. If the mass involves the area of the spine adjacent to nerve
roots, radicular pain may be reproduced.
e. Jacksons compression test ( Figs. 5.5 and 5.6 ) : this patient is instructed to rotate this
or her head first to the right and then to the left. The examiner exerts gentle pressure to
the top of the patients head after each movement. This test place increased pressure on
the cervical facet joints and cause narrowing of the neural foramen and reproduce neck
pain due to facet arthropathy and/ or upper extremity redicular pain due to nerve root
compression.
f. Lhemittes sign : production of paresthesias dysesthesias in the arms or legs upon
flexion of the cervical spine. It may be caused by a large disc herniation or bony
compression of the anterior cord in patients with a narrowed cetral canal it may also
occur n patients with rheumatoid arthritis with associated instability or in patient with
multiple sclerosis affecting the cervical spinal cord, tumors, and syringomyelia.1 this
indicates changes in the matter of the spinal cord and may be secondary to cervical
myelopathy or multiple sclerosis.
g. Adsons maneuver (Fig. 5.7) : this test is used to rule out compression of the subclavian
artery by an extra cervical rib or scalene muscle bands, which may result to thoracic
outlet syndrome. The patients arm hangs at their side and the head is extended and
rotated toward the effected side. The patient is then instructed ti breathe deeply and hold

their breath while the radial pulse is monitored. The test is considered positive if the
radial pulse disappears.
h. Grip-release test is an inability to open and close fist rapidly because of weakness and
spaticity of the hans.
Sensory examination
Light touch, pressure sense, pin prick along with temperature and proprioceptoin should be done in
both upper limbs for comparisons in case of radiculopathy, CRPS, peripheral neuropathy and in all
four limbs in case of myelopathy. Progressive sensory loss is considered as red flag.
Motor Examination
Motos function are tested as per standard grading 0 to 5: (0) having no function, (1) having trace, (2)
having full range of joint motion with gravity eliminated, (3) having antigravity function, (4) having
function against slight resistance, and (5) having normal strength against resistance. Progressive
decrease in motor grading or grade 3 or less is red flag. Lower motor neuron disease is indicated by
weakness, hypotonia and fasciculations. Upper motor neuron disease is indicated by spasticiy.
Reflexes
Deep tendon stretch reflexes should be performed and graded 0 to 3 : (0) being no response, (1)
being hyporeflexive, (2) being normal, and (3) being hiperreflexive. To facilitate reflex testing, it
may be helpful to use musle loarding or Jendrassiks maneuver (performed) by having the patient
flex both sets. Of fingers into a hook-like form, interlocking the hand , and pulling apart).this
maneuver creates diversion to help relax the patient and asses lower extremity reflexes. If difficulty
with reflex testing persists, the clinician should ensure that no peripheral neuropathy is present.
a. Biceps reflex (Fig. 5.8) : C5 is tested by striking the biceps tendon with elbow flexed.
b. Supination reflex (Fig. 5.9) : C6 mediated and tested with elbow semiflexed with
forearm midpronated by striking over brachioradialis tendon over radial tubercle.
c. Tricepss reflex (Fig. 5.10) : C7 mediated and tested with elbow flexed and triceps
tendon is striked above olecranon process.
d. Babinskis test is performed by stroking the lateral plantar aspect of the foot with a
pathologic response indicated by an upgoing great toe indicatingan upper motor neuron
lesions.
Lower limb reflexes, knee and ankle reflex should be checked in case of myelopathy in
which they will be exaggerated due to upper motor neuron lesion, where us upper limb
reflexes will be diminished due to lower motor neuron lesion.
Other Systemic Examination
a. Cardiovascular : to rule out referred pain of angina in neck cardiovascular
examination must be carried out thoroughly. Blood pressure, pulse rate, heart rate,
rhymthm must be evaluate.
b. Respiratory : pancosts tumor of lyng apex cause lower brachial plexus invasion and
neck pain and plexopathy and diaphragmatic involvement can cause referred neck

pain. Respiration rate, pattern and lung field auscultation helps to rule out lung
pathologies.
c. Abdominal : palpation of abdominal organs for enlargement and infection.
INVESTIGATIONS
1. Routine blood investigation with ESR and CRP: It should be advice in all cases
suspecting of inflammatory arthropathy.
2. X-ray AP and lateral view : bony changes are well recognized by X-rays, hance can
identify fracture, degenerative osteophytes and cervical rib.
3. CT SCAN : Bony abnormalities, hemorrhange can be see well wit CT scan and advice in
trauma cases, facet joint, uncovertebral joint abnormalities.
4. MRI : Soft tissue like disc, nerve roor, canal diameter, muscles, vascular, aneurysm and
abnormalities are best seen in MRI
5. DIAGNOSTIC BLOCKS : It help infinding pain generators. Various block can be
performed and are evidence based. More than 50% pain relief is considered positive.
a. Occipital nerve block- in case of occipital neuralgia but can be positive in
migraine and tension type headache.
b. Medical branch block- for facet joint arthropathy
c. Cervical interlaminar epidural injections- in case of radiculopathy and prolapsed
disc.
d. Tringger point injections in myofascial pain syndrome
e. Stellate ganglion block in case of CRPS
6. EMG and NCV : These studies will be abnormal when nerves are involved, specially
large fibers and abnormal inradiculopathy and nerve entrapment syndromes. In CRPS,
these studies are usually normal
7. Ultrasound neck and shoulder done when muscles or tendon tear are suspected.