case study 4 -- neck pain

Elizabeth Ho Moon Liang

CASE STUDY 4 Neck Pain

Dated: 7 June 2007 (edited 5 December 2007)

Patient’s Name: Katrina Kum NIRC: S09*****D

TABLEOFCONTENTSPage

1. Patient Profile 2

2. Health Assessment 2

3. Physical Examination 3

4. Diagnosis 4

5. Management 5

6. Evaluation 7

7. Learning points 7

MdmKum, a 55-year lady, came to polyclinic on 3 rd February 2007 with chief complain ofneck pain. This case study will focus of the approach to neck pain andmanagement of neck pain.


PATIENT PROFILE

Mdm Katrina Kum (S09*****D), a 55-year lady, was attended by me and my preceptor for her

neck pain on 3rd February 2007. Her previous consultations with Hougang polyclinic were

unrelated to the attended problem. Her medical history includes cardiomegaly, hypertension,

hyperlipidemia, iron deficiency anaemia and gastro-esophageal refluxe, which the private

general practitioner currently manages.

CURRENTMEDICATIONS

1) Atenolol/ Nifedepine (50/ 20mg) 1 tablet every morning

2) Simvastatin (Zocor) 20mg every night

3) Omperazole (Losec) 20mg every morning

4) Isosorbide Dinitrate 10mg three times a day

5) Glyceryl Trinitrate 500mcg when necessary under tongue

DRUGALLERGY:

Nil reported

HEALTHHISTORY

Chief Complains:Mdm Kum complained of neck pain and left shoulder pain for 9 days. Pain

score 6 to 7 over a 10-point scale. Pain is described as pulling tight and constant in nature.

Movement of the left arm will aggravate the pain. She claimed that the neck pain is more painful

than her left shoulder pain. She cannot identify any relieving factors. There is no reported history

of trauma or extensive usage. There is also numbness and tingling sensation down the left arm

and fingers. No loss of strength of the left arm is reported.

Mdm Kum had preceding occipital, neck-ache and bilateral shoulder ache for 2 years which she

consulted private doctor. The pain was controllable till now. She used paracetamol and other non

-pharmacological methods like massage for her previous pain control. There is no muscle

weakness. No chest pain or shortness of breath is reported.


PHYSICALEXAMINATION

General appearance –. Comfortable. Has a BMI of 21.2. Afebrile.

Nails – No pallor and clubbing seen.

Eyes – No conjunctivae pallor noted.

Tongue – Moist. Not cyanosis.

a) CVS examination

Pulse – 60 beats per minute. Regular in nature.

Blood Pressure – 150/ 80mmHg. (Taken medications this morning).

Heart – Apex beat palpable between 4th and 5th intercostals space. No thrills and heave felt. S1

and S2 sounds heard. No murmurs detected. Jugular venous pressure not raised. No pedal edema.

b) Lungs examination

Lungs – Respiration rate 12 breaths per minute. Trachea is not deviated. Chest expansion is

equal bilaterally. Vesicular breath sounds heard. No wheezes or rhonchi are detected upon

auscultation.

c) Neck, Back and UpperArms examination

Tenderness is felt along the paramedian neck muscle, left trapezius muscle and over the left

shoulder. Range of movement of left shoulder joint is full. Sensation is diminished over

dermatome regions C4 to C6 of the left upper limb. Biceps power of left arm is diminished

compared to the right arm.


DIAGNOSES

Probable diagnosis: Cervical spondylosis with degenerative disc disease at C4 to C6 level

Differential diagnoses:

1) Musculoligamentous sprain

2) Acute disc herniation

3) Angina pectoris

4) Space-occupying lesions

Musculoligamentous sprain is another most common presentation in the polyclinic that will

result in neck pain and shoulder pain. However, the pain related to dermatome areas seem is not

a characteristic of this differential diagnosis. The pain that is related to dermatome areas is also

known as radiculopathy pain, can be caused by a particular nerve root impingement. Angina

pectoris is in the list of the differential diagnosis to be excluded because Mdm Kum has a high

risk of cardiovascular event due to the hyperlipidemia, hypertension, cardiomegaly and iron

defieciency anemia. An ECG should definitely be ordered if there are any associated cardiac

symptoms like exertional dyspnea or shortness of breath. Although there is 1) an absence of

cardiac signs and symptoms, 2) the characteristic of pain described as constant over the past 9

days and 3) the mechanical nature of pain, which is aggravated when she moves her arm,

although an ECG was not done, on reflection it is strongly encouraged to do an ECG then. Space

-occupying lesions are the least likely in this case due to the absence of any malignancy or past

malignancy history. However, it is always necessary to keep malignancy as a possible cause at

the back of the mind when formulating the diagnosis.

Laboratory Tests

Cervical spine x-ray (anterior posterior and lateral) is ordered. The report showed that there is

loss of normal lordosis. The spine is otherwise normal in alignment. Degenerative changes are

noted in the form of marginal osteophytes, reduced C5-C6 disc space and facetal arthropathy.

The vertebrae and intervertebral disc spaces are otherwise normal. There is no prevertebral or

paravertebral soft tissue abnormality. There is partial ossification of the ligamentum nuchae.

There is no atlantoaxial subluxation.

Impression:Cervial spondylosis with degenerative disc disease at C5-C6 level.


MANAGEMENT

Prevalence. Neck pain has been described in literature as an extremely common but nonspecific

symptom (Douglass and Bope, 2004). The prevalence of neck pain at any given time is 9%.

These numbers increase with age and tend to be higher in women.

Diagnosis and Differentials. The approach to neck pain is complex. Till to date, there is no

clinical guidelines or clinical algorithms to conceptualize the clinical approach to neck pain. The

list of differential diagnoses can be seen at Table 1. The clinical approach to neck pain can be

simplified by dividing the findings at presentation to into axial neck pain, radiculopathy,

myelopathy or some combination of these three (Rao, 2002 and Douglass & Bope, 2004).

Description of each category is summarized in Table 2.

Musculoskeletal

1) Muscular ormusculoligamentous sprain

2) Veterbral fracture/ dislocation

3) Spinal stenosis4) Herniation of veterbral disc/

Disc prolapse

5) Space-occupying lesions

Inflammation

1) Ankylosing spondylitis2) Osteomelitis3) Meningitis

4) Rheumatoid arthritis

Referred Pain

1) Angina pectoris2) Subarachnoid haemorrhage3) Oesophageal foreign bodies

Magnilancies1) Primary neoplasia

2) Metastasis

Table 1: Differential Diagnoses to Neck Pain

Axial Neck Pain Radiculopathy Myelopathy

GeneralDescription

Uncomplicated neckpain

Motor and/or sensory changesin the neck and arms

Subtle and variedpresentation

PresentingSymptoms

· Pain or soreness inposteriorparamedian neck

muscle

· With radiation tooccuput, sholder,or parascapular

region.

· Stiffness in one or

more directions ofmotion

· Headache

· Local warmth ortingling

· Localized areas ofmuscle tenderness

· Pain is sharp, tingling, orburning.

· Pain in specificdermatomal distribution inthe upper extremity.

· Not always unilateral

· Onset insidious but may beabrupt

· Aggravated by armposition and extension or

lateral rotation of head.

· Arm pain (99%)

· Sensory deficits (85%)

· Neck pain (79%)

· Reflex deficits (71%)

· Motor deficits (68%)

· Scapular pain (52%)

· Subtle findings thathave been present foryears or

· Acute paresis

· Insidious clumsiness,weakness, or stiffness

in the upper andlower extremities.

· Pain is deep andaching in neck andshoulder

· Arm and neckstiffness are common

· Varied presentations

should raise clinicalsuspicion

Table 2: Description and Presentation Symptoms between different categories of Neck Pain


For this case study, Mdm Kum appeared to present predominantly with radiculopathy. She

complained of a pulling tight pain over the neck migrating down to the upper arm. This

presentation coincides with the fifth cervical nerve dermatome distribution. Primarily the fifth

cervical nerve innervates the deltoid muscle. Radiculopathy of the fifth cervical nerve can begin

at the superior aspect of the shoulder and extending laterally to the mid-part of the arm. Sensory

loss over the (sixth cervical dermatome distribution) lateral aspect of left bicep, lateral aspect of

the forearm to the dorsal aspect of the web space between the thumb and index finger is also

present. Finally arm movement aggravates the pain. It is important to rule out pathological

shoulder condition. There should be an absence of pain with a range of motion of the shoulder

and the absence of impingement signs at the shoulder if pathological shoulder involvement is not

present (Rao, 2002).

Pathogenesis of cervical spondylosis. The initiating event in this degenerative process seems to

be dehydration of the intervertebral disc. The dehydration causes a loss of elasticity and

increased stresses on the vertebral end plates. Ospteophytes are developed in response to this

increased stress and defectively increase the available surface area thereby decreasing the overall

force on the end plates. The osteophytic spurs may extend from the lateral aspect of the disc, and

from the zygapophyseal and intervertebral joints and cause encroachment of the exiting nerve

roots in the intervetebral foramen. Compression of the nerve root by this hard disc can result in

conduction slowing across the affected segment leading to radicular symptoms.

Treatment and Plans. As Mdm Kum experienced sensory loss. She was referred to the orthopedic

specialist to have a further evaluation and treatment. For this consult, the management of Mdm

Kum’s neck will be on pain control. The approach to pain control is the same as the previous

case study on knee pain control. As Mdm Kum has tried paracetamol for her pain before and it

did not effectively reduce the pain for her. A different but stronger paracetamol preparation is

prescribed to her for pain control. Orphenadrine 35mg/ Paracetamol 450mg 2 tablets 3 times

daily or when necessary was prescribed. In addition to that, application of Proxicam 0.5% gel 2

times daily was also prescribed.

Cervical spondylosis can have complications such as progression to cervical myelopathy. Thus,

it is also important to advise Mdm Kum some home physical therapy before her appointment


with the specialist. The main stay of conservative treatment using physical therapy is

immobilization (Galhom and Wagner, 2005).

There are some measures to prevent deterioration of cervical spondylosis. Activities that Mdm

Kum should avoid include (a) high impact exercise (e.g. running and jumping) (b) holding the

head in one position for a long time and (c) prolonged neck extension. Activities that Mdm Kum

is encouraged to do include maintaining regulat cervical ROM with daily ROM exercises and

maintaining neck muscle strength especially neck extensor strength. Appendix A shows a set of

exercises, adapted from Kasier Permanentle patient education book, for patients with cervical

spondylosis. Osteoporosis retardation is also important in the management of cervical

spondylosis. Aspects of osteoporosis are discussed in the previous case study of knee pain.

EVALUATION

Mdm Kum will be followed up with the orthopedic department. Thus her subsequent visit to us

will be focusing on the pain control and assessing for deterioration of symptoms.

APN RFLECTION AND LEARNINGPOINTS

Neck pain is very common symptom, which can be complicated to diagnose and manage. An

APN-intern has to be careful when seeing a patient with neck pain. It is best that for the time

being that cases with neck pain has to be managed under the supervision of a physician.

Attaining a proper health history and physical assessment will facilitate the physician to make a

more accurate diagnosis.

REFERENCESDouglass, A.B. and Bope, E.T. (2004). Evaluation and treatment of posterior neck pain in familypractice. Journal of the American Board of Family Medicine, 17(S): S13 – S22. Retrieved from

http://www.jabfm.org/cgi/reprint/17/suppl_1/S13.pdf on 15 April 2007.

Galhom and Wagner (2005). Cervical spondylosis. Retrieved from http://www.

emedicine.com/pmr/topic27.htm on 15 April 2007.

Rao, R. (2002). Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology

natural history, and clinical evaluation. Journal of Bone and Joint Surgery, 84: 1872-1881.Retrieved from http://www.ejbjs.org on 28 March 2007.

case study 4 -- neck pain

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