12/9/2016

1

Pain in the Neck: Common Problems in the

Cervical Spine

Conor W. O’Neill, M.D.Clinical ProfessorDepartment of Orthopaedic SurgeryNon-operative Spine ServiceUCSF

DisclosuresStock Ownership: Relievant (0.17%), Nocimed (0.70%).

• Functional anatomy• Pathology• Clinical evaluation• Case studies

Outline

MyelopathyRadiculopathyMechanical neck pain

Cervicogenic HACervicobrachial syndrome

• Live exam

Functional Anatomy

12/9/2016

2

12/9/2016

3

12/9/2016

4

VR

DR

SVN

12/9/2016

5

12/9/2016

6

Pathology

Disc Herniation

Spondylosis

12/9/2016

7

12/9/2016

8

48 hours after MVA. T2 image shows focal hematoma (∗), trace prevertebral hemorrhage (thick arrow), linear area of altered signal intensity anterior annulus (long thin arrows), epidural hematoma (short thin arrow).Published in: Suzanne E. Anderson; Chris Boesch; Heinz Zimmermann; André Busato; Jürg Hodler; Roland Bingisser; Erika J. Ulbrich; Andreas Nidecker; Carlos H. Buitrago-Téllez; Harald M. Bonel; Paul Heini; Stefan Schaeren; Matthias Sturzenegger; Radiology 2012, 262, 567-575.

Parasagittal image shows prevertebral soft-tissue hemorrhage (long arrow) and epidural hematoma at the C7 level (short arrows). Published in: Suzanne E. Anderson; Chris Boesch; Heinz Zimmermann; André Busato; Jürg Hodler; Roland Bingisser; Erika J. Ulbrich; Andreas Nidecker; Carlos H. Buitrago-Téllez; Harald M. Bonel; Paul Heini; Stefan Schaeren; Matthias Sturzenegger; Radiology 2012, 262, 567-575.

Transverse STIR image near angle of mandible shows perimuscular hemorrhage (thin arrows), right muscle strain (∗), and left facet asymmetry (thick arrow).Published in: Suzanne E. Anderson; Chris Boesch; Heinz Zimmermann; André Busato; Jürg Hodler; Roland Bingisser; Erika J. Ulbrich; Andreas Nidecker; Carlos H. Buitrago-Téllez; Harald M. Bonel; Paul Heini; Stefan Schaeren; Matthias Sturzenegger; Radiology 2012, 262, 567-575.

12/9/2016

9

Clinical Evaluation

12/9/2016

10

12/9/2016

11

12/9/2016

12

Case Studies• Myelopathy• Radiculopathy• Mechanical neck pain• Cervicogenic headache• Cervicobrachial syndrome

66 y/o retired data entry clerk• Line dances, active in church

• Enlarged tonsil on routine exam, cancer workup negative

• Spinal stenosis noted on neck MRI done as part of cancer workup

12/9/2016

13

44 yr old stay-at-home mom

• Very fit, regular vigorous exercise• No prior neck problems• Woke up with severe pain (8/10)• No myelopathy, 4/5 weakness triceps

and wrist flexors• 6 weeks conservative care

xxx xxxxXxxxxxxxxxxxx6/7

6/7

Left

12/9/2016

14

Keyhole foraminotomy

12/9/2016

15

xxx xxxxXxxxxXxxxxxxxxxxxxxxxxxxxx

xx xxx

xxxxxxxxxxxxx

• Nonspecific term describing some combination of pain, numbness, tingling, weakness in the neck and/or upper extremity, without specific pathology

• Diagnosis of exclusion� Cervical radiculopathy� Shoulder and rotator cuff pathology� Peripheral entrapment neuropathies� Parsonage-Turner syndrome (acute brachial radiculitis)

• Probably due to some combination of myofascial pain, neurogenic thoracic outlet syndrome, elevated pain sensitivity

Cervicobrachial syndrome

12/9/2016

16

76 year old male

• Healthy, active• Chronic stiff neck• 4 month history of severe left sided

neck pain• No better with PT, NSAID’s

xxx

3/4 4/5

5/6 6/7Right Left

12/9/2016

17

46 y/o anesthesiologist• Healthy, active, master’s

swimmer

• 6 month history of neck pain after sledding injury

• Still working, can’t swim

Right

Left

C3/4 C3

C3

12/9/2016

18

64 y/o law firm CFO• Passionate hunter (shoots

rhino with long-barreled handgun)

• Freak injury while duck-hunting

• Neck pain with numbness and tingling left shoulder

xxx x

oooo

Left

C4

12/9/2016

19

56 y/o tech industry executive• Whiplash injury while

traveling in Singapore• 6 month history of neck pain,

minimal response to PT, medications

• Pain radiates into occiput, HA aggravated by neck movement

• Still working, medical care being paid for by Singapore auto carrier

12/9/2016

20

Woke up during the night with severe pain at the base of her skull after "rickety carnival rides” at the Napa County Fair.

Working, no other activities, VAS=8, occasional pain pills

48 y/o attorney with neck pain

12/9/2016

21