Case Study 4 -- Neck Pain

CASE STUDY 4 Neck Pain Dated: 7 June 2007 (edited 5 December 2007) Patient’s Name: Katrina Kum

NIRC: S09*****D

TABLE OF CONTENTS 1. Patient Profile

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2. Health Assessment

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3. Physical Examination

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4. Diagnosis

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5. Management

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6. Evaluation

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7. Learning points

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

Elizabeth Ho Moon Liang

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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. CURRENT MEDICATIONS 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 DRUG ALLERGY: Nil reported HEALTH HISTORY 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.

Elizabeth Ho Moon Liang

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PHYSICAL EXAMINATION 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 Upper Arms 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.

Elizabeth Ho Moon Liang

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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.

Elizabeth Ho Moon Liang

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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 Inflammation 1) Muscular or 1) Ankylosing spondylitis musculoligamentous sprain 2) Osteomelitis 2) Veterbral fracture/ dislocation 3) Meningitis 3) Spinal stenosis 4) Rheumatoid arthritis 4) Herniation of veterbral disc/ Disc prolapse 5) Space-occupying lesions Table 1: Differential Diagnoses to Neck Pain

Referred Pain 1) Angina pectoris 2) Subarachnoid haemorrhage 3) Oesophageal foreign bodies Magnilancies 1) Primary neoplasia 2) Metastasis

Axial Neck Pain Uncomplicated neck pain

Radiculopathy Myelopathy General Motor and/or sensory changes Subtle and varied Description in the neck and arms presentation · Pain is sharp, tingling, or · Subtle findings that · Pain or soreness in burning. have been present for posterior years or · Pain in specific paramedian neck dermatomal distribution in · Acute paresis muscle the upper extremity. · Insidious clumsiness, · With radiation to · Not always unilateral weakness, or stiffness occuput, sholder, in the upper and · Onset insidious but may be or parascapular lower extremities. abrupt region. Presenting · Pain is deep and · Aggravated by arm Symptoms · Stiffness in one or aching in neck and position and extension or more directions of shoulder lateral rotation of head. motion · Arm and neck · Arm pain (99%) · Headache stiffness are common · Sensory deficits (85%) · Local warmth or · Varied presentations · Neck pain (79%) tingling should raise clinical · Localized areas of · Reflex deficits (71%) suspicion muscle tenderness · Motor deficits (68%) · Scapular pain (52%) Table 2: Description and Presentation Symptoms between different categories of Neck Pain

Elizabeth Ho Moon Liang

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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

Elizabeth Ho Moon Liang

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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 LEARNING POINTS 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.

REFERENCES Douglass, A.B. and Bope, E.T. (2004). Evaluation and treatment of posterior neck pain in family practice. 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. Elizabeth Ho Moon Liang

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