History

• Duration, onset, aggravating, relieving factors, and outcome of management to date. Pain distribution and severity (VAS)
• Radiculopathy symptoms (injury or damage to nerve roots in the area where they leave the spine)
  • shooting or toothache type pain and / or sensory disturbance (paraesthesia / numbness) in dermatomal fashion with / without loss of strength

• Myelopathy symptoms (spinal cord injury – often compression)– upper/ lower limb weakness or altered sensation, loss of dexterity in hands, loss of balance/ coordination when walking, disturbance of bowel or bladder function (See Red Flags)

Past Medical History

Specifically:

• Rheumatoid Arthritis, neck trauma, previous neck surgery, cancer, congenital disorders which may rarely predispose to atlanto-axial subluxation (such as Down's syndrome), immunocompromise, TB, osteoporosis (particularly in minor trauma)

Examination

• Observation of muscle wastage or deformity
• Inspect the skin for papulovesicular rash, petechiae or purpura suggestive of meningitis
• Palpate the neck for tenderness and lymphadenopathy which could suggest infection, malignancy, or an inflammatory cause
• Range of motion of spine and upper limbs particularly shoulder noting any reproduction of pain
• Neurological examination power, tone, reflexes, and sensation in the arms and legs including gait if myelopathy suspected

Tests for cervical radiculopathy:

• Tests for cervical radiculopathy
• Spurling’s test

Tests for cervical myelopathy:

• Tests for cervical myelopathy
• Tandem walking, Romberg’s, hyperreflexia, up going plantars, hypertonia, clonus, Babinski sign, inverted supinator and grip release signs
• Lhermitte's sign: flexion of the neck causes an electric shock-type sensation that radiates down the spine and into the limbs
• Hoffman sign: Examiner will extend the distal phalanx of the long finger (or flick the end of the digit), then rapidly release this digit- the patient will respond with a reflex flexion of the thumb and/or index finger

Differential Diagnosis:

• Joint Pathology
  • Shoulder conditions - e.g., adhesive capsulitis or impingement syndrome
  • Wrist conditions - e.g. carpal tunnel syndrome
  • Elbow conditions - e.g., tennis elbow

• Non-specific neck pain - neck pain without radicular / myelopathic symptoms. Common causes include postural pain, minor strains
• Acute torticollis - neck pain that is due to acute spasm with no obvious underlying cause
• Cervical Spondylitis - osteoarthritis of the cervical spine
• Polymyalgia Rheumatica - can cause pain and weakness upper limbs similar to radiculopathy
• Malignancy - tumours arising from thyroid, oesophageal, pharyngeal, and lung tissue have been reported to compress individual cervical nerves
• Neurological Causes
  • Meningitis
  • Parsonage-Turner syndrome (brachial plexopathy)

• Vascular conditions
  • Thoracic outlet syndrome
  • Carotid or vertebral artery dissection

Red flag signs and symptoms include:

• Recent rapidly progressive and deteriorating myelopathy (see ‘Assessment’ section) e.g., sudden worsening of mobility, upper limb function and/or bowel or bladder incontinence, erectile dysfunction, or difficulty passing urine. Refer to the Emergency Department.
• Malignancy/ Spinal Infection: Fever, night sweats, unexplained weight loss. Excruciating pain, intractable night pain, pain that is increasing, exquisite tenderness over vertebral body, generalised neck stiffness. Cervical lymphadenopathy.
• Meningism: nausea or vomiting, new and severe headache, photophobia or phonophobia, visual loss.
• Signs of carotid artery dissection: headache, neck and facial pain ipsilateral to the dissection, transient blindness, syncope, pulse synchronous tinnitus, Horner’s syndrome

• Cervical X-ray - NOT routinely required
• MRI should NOT be requested in a primary care setting.
  • MRI will be requested by the spinal interface team as appropriate.
  • To manage patient expectations, patients should be informed they may not require imaging if being referred to specialist clinic. This should be reinforced that this is a good sign and there is nothing concerning in their presentation.

• Shoulder X-ray - may be helpful to exclude shoulder joint involvement when shoulder ROM is reduced and painful
• Neurophysiology (nerve conduction studies) to exclude neural entrapment Carpal tunnel or brachial neuritis (Parsonage-Turner syndrome)
• Blood Tests are appropriate in some patients to exclude differential diagnoses (see above) e.g., suspicion of inflammatory back pain, infection, or cancer.

1) Non-specific neck pain:

a) Advice and education:

• Reassurance — neck pain is a common problem that usually resolves within a few weeks.
• Advise that a firm pillow may provide comfort at night. It should provide lateral support and support the hollow of the neck and the position should be comfortable. Advise against sleeping with more than one pillow.
• Encourage activity and a return to a normal lifestyle (including work) as soon as possible. However, advise the person not to drive if the range of motion of the neck is restricted.
• Discourage the use of cervical collars because this restricts mobility and may prolong symptoms.
• Signpost to information sites such as Versus Arthritis

b) Pharmacological interventions:

• Consider oral non-steroidal anti-inflammatory drugs (see section 10.1.1 Non-Steroidal anti-inflammatory drugs (NSAIDs)
  • Prescribed at the lowest dose and shortest possible period of time

• Consider the use of neuropathic analgesia if there is radiation without features suggesting the need for further investigation

c) Exercise/Physiotherapy:

• Referral to a physiotherapist for a multimodal treatment strategy — this may include stretching and strengthening exercises, range of motion exercises, and some form of manual therapy.
• Advice on exercise options. Depending on patient preference and availability, exercise such as yoga, Pilates, Tai Chi, or Qigong can be useful. Information on simple neck exercises is available from sites such as Versus Arthritis and the Chartered Society of Physiotherapy.

d) Further options in specific situations:

• Consider referral for psychological therapy if there are psychological symptoms or risk factors or if pain is chronic.
• Consider referral to occupational health for people with neck pain related to their work.

2) Cervical Radiculopathy

a) Advice and education

• Provide reassurance and information — the long-term prognosis of people with radiculopathy is good and most cases improve without surgery. Timescale varies but substantial improvements tend to occur within the first 4 to 6 months post-onset. Time to complete recovery ranged from 24 to 36 months in, approximately, 83% of patients (Wong et al 2014).

b) Exercise/Physiotherapy

• Consider a referral to physiotherapy

c) Follow up

• Consider a follow-up review. Repeat examination can identify the resolution or progression of symptoms and any new neurological signs.

3) Cervical Myelopathy

a) Refer

• Refer urgently to the spinal interface service if symptoms stable or to the Emergency Department if rapidly progressive (see red flags)

b) Safety net

• Safety net patient regarding deterioration of symptoms
• Signpost to www.myelopathy.org

1) Refer to the Spinal Interface Service

The Spinal Interface service will complete a comprehensive assessment, refer for diagnostic tests or refer onto pain management and spinal surgeons via the Spinal MDT where appropriate.

Urgent – patients without red flags requiring same-day assessment who:

• have stable or slowly progressive myelopathic symptoms and / or signs (rapidly progressive to Emergency department)
• have symptoms and signs of cervical radiculopathy with progressive and severe neurological deficit (provide details of neurological examination to aid triage of referral)
• have symptoms and signs of cervical radiculopathy with intolerable pain despite appropriate primary care management (provide details of neuropathic pain management to aid triage).

Routine - patients without red flags or urgent features who:

• have neck pain AND symptoms/ signs of radiculopathy who have failed 6 weeks primary care conservative management.
• have had previous surgical intervention in the cervical spine

Referrals made outside of these referral criteria will be triaged based on the information provided and managed appropriately. To facilitate this process and maintain patient safety, please ensure that the reason for referral and clinical concerns are clearly stated in the referral letter.

2) Refer To Pain Management Service:

• If patient has neck pain AND no improvement with physiotherapy / primary care conservative management and both the GP and the patient feel a pain clinic assessment would be beneficial.
• Referrals should explicitly state past medical history including drug, alcohol, and mental health to enable appropriate triage. Wider mental health must be addressed separately and supported appropriately in primary care. Patients should not have unstable severe mental illness otherwise referrals will be returned until this has been managed.
• Signpost patients to MyHealth-Devon information on pain.

Referral Instructions

Refer to the Spinal Interface Service via e-RS
Specialty: Orthopaedics

Clinic Type: Spine – Back Pain (not scoliosis/deform)

Service: DRSS-South Devon & Torbay-Orthopaedics-Spine-(PCT) – Devon ICB-15

Refer to the Pain Management Service via e-RS

Specialty: Pain Management

Clinic Type: Pain Management

Service: DRSS-South Devon & Torbay-Pain Management-Devon ICB-15N

Referral Form

DRSS Referral Form

GP Information

BMJ (2022) Assessment of neck pain. BMJ Best Practice.

NICE - Neck pain - non-specific

NICE - Neck pain - cervical radiculopathy

Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 2014 Aug 1;14(8):1781-9.

Myelopathy.org

Patient Information

Versus Arthritis - Neck Pain

NHS Conditions - Neck Pain and stiff neck

Your physio - Cervical Radiculopathy

Myelopathy.org

Pathway Group

Mr S Pritchard. Neurosurgical Spinal Extended Scope Physiotherapist (Neurosurgery Department University Hospitals NHS Trust)

Mr Paul Fewings. Consultant Neurosurgeon. (Neurosurgery Department University Hospitals NHS Trust)

Dr N Keysell DRSS GP Planned Care Lead

Publication date: October 2024