INTRODUCTION

Neck pain is one of the must common complaints of patients in pain clinic.
Frequency of neck pain is increased due to bad posture or jobs, which require
prolonged flexion of the neck such as computer work work or over the head work.
The intial evalauation should be comprehensive in order to ascertain not only the
etiology of physical symtomatology, but also the impact of the patients disability has
on their psychosocial environment.
ETIOLOGY
Apart from trauma, tumor and infection, which are red flag, the are various caouse of
chronic neck pain that are given in Table 5.1.
RED FLAGS
Though chronic neck pain is commonly due to myofascial pain or facet join
arthropathy, red flags should be ruled out. As cervical canal is almost completely
occupied by spinal cord, minor reduction in canal diameter will lead to cervical
myelopathy, hence careful assessment is important to identify early signs of
myelopathy, occasional patients develop high spinal respiratory insufficiency, and
death. Table 5.2 enlisted red flags in neck pain
DETAIL HISTORY OF PATIENTS
The perpose of a thorough history with determination of the location, pattern, and
distribution of the patients pain is to establish
Bersambung

Muscles are usually localized, nerve root compression pain is dermatomally

distributed and pain along the peripheral dermatoal and / or myotomal distribution
suggets lesion of the cervical or brachial plexus or their branches. Axial neck pain is
due to internal disc disruption, bilateral facet joint. Paramedial pain suggestive of
facet joint and its reffered pain, myofascial pain or other neck pathologies.
Widiespread pain can be seen in fibromyalgia, osteoarthritis, rheumatoid, arthritis,
SLE, hypothyroidism or somatization in severe depressen. Infection and neoplasms
can cause axial neck pain through bone distruction with irritation of vertebral body
periosteal nerves and altered biomechanics of the facet joints and cervical disks.

3. Raditoin of pain
Cervical and vrachial referral pattern may be secondary to myofascial trigger points
or referred from the shoulder,heart, lung, viscera, or temporomandibular joint to the
neck region owing to ovarlaping nerve distribution. Referred pain to the occiput
usually indicates pathologic changes in the upper cervical spine and may radiate
down the neck and to the ear. If the face, head or tongue is involved, the upper three
nerve roots of the cervical flexus may be affected. Numbness of the neck, shoulder,
arm, forearm, or fingers indicates involvement of C5-T1. The referral area in cervical
region is listed in Table 5.3.
4. Duration of Pain
Avute pain due to trauma, infection dics prollapse with neurodeficit, vascular
dissection with hemodynamic instabilities must be aggressively investigated and
treated to avoid major complication and death. More gradual or insidious onset is
common in progressive degenerative, inflammatory of malignant process.
5. Character of Pain
Pain due to musculosskletal origin are generally dull aching, deep, throbbing in
nature, where as neuropathic pain are sharp, shooting, electric shock like with
tingling and numbness. Nerve root involvement pain is dermatomally distributed and
describrs along these areas. Dermatomally, C1 and C2 innervate the occiput region;
C3 dan C4, the nape of the neck;C5, the deltoid region;C6 the radial aspect of the
forearm; C7, the long finger; C8, the ulnar border of the hand; and T1, the medial
broder of the arm. T2-12 provide innervations to the chest and abdomen, with T4
being at the nipple line, T10 at the umbilicus, and T12 at the inguinal ligament.
Articul symptoms arise from the facet and vertevral joint causing stiffness and
localized pain. Poorly localized, burning pain characters are seen in sympathetically
mediate pain. Hyperesthesia, allodynia and burning pain suggest complex regional
pain syndrome (CRPS).
6. PROGRESSION of NEURODEFICITS
Any progression of sensory of motor dysfunction due to nerve root or cord
compression must be considered as red flags and treated accordingly. Myelopathy can
be due to mass effect from a tumor ofr infection or instability owing to systemic

arthritis or connective tisuue disorders, but it is often a result of advanced

degenerative changes within the cervical spine and large central PIVD. There can be
bladder and bowel disturbance. Upper motor type of lesion in upperlimb at the level
above compression, describe as weakness and looseness in upper limb.
Aggravating and relieving factors
Pain due to spine involvement will be aggravated during movements. Facet joint pain
will be aggravated by neck extension, lateral flexion and lateral rotation. Atlanto
occipital joint arthritis is worsened with propocative neck flexion and extension,
worsened with rotation. Discogenic pain will be more in forward flexion. Myofascial
pain will be aggravated by muscle stretching and over
tender points
palpation.radiculopathy pain will be relieved by arm abducted and externally rotated
over head. Chronic inflammatory pain is often worse after a period of inactivity and
improves with exercise. Degenartive arthritis is often exacerbated by exercise and
improves with rest.
Associated symptoms
Morning stiffness, polyarthritis, rigidity, skin manifestation are associated symptoms
in inflammatory arthropathy. Rheumatoid arthritis often involves the cervical
spaine,initially causing stiffness and later causing pain. After the hands and feet, the
cervical spine is the most common site of disease involvement in rheumatoid arthritis.
Ankylosing spondylitis often affects the entiremotion and chest expansion and later
involvement of the cervical spine. Fever, night pain and weight loss suggestive of
infectious etiology.
Dyspnea can be related to a deficit in the C3-5 innervations of the diaphragm.
Palpitations and tachycardia secondary to cervical spine pathology can be
differentiated from other causes by the fact that these symptoms are associated with
unusual positions or hyperextension of the neck. This hyperextension is caused by
irritation of C4 innervation of the diaphragm and pericardium or by irritation of the
cardiac sympathetic nerve supply. Drop attacks suggest posterior circulation
insufficiency. Sever night pain, anorexia, progressive myelopathy is associated with
malignancy.
Eye ande ear symtomps may arise from irritation of the plexus surrounding the
vertebral and internal coratid arteries. Eye symtomps can manifest with blurring of
vision relieved by changing neck position, increased tearing, orbital and retro-orbital

pain, and description of eyes being pulled backward or pushed forward. Altered
equilibrium with associated gait disturbances may result with irritation of the
surrounding sympathetic plexus from vertebral insufficiency. Hearing can be affected
with tinnitus and altered audirory acuity. Throat symptoms, including dysphagnia,
may be related to anterior vertebral osteophytes causing direct compression and
cranial nerve and sympathetic nerve communication.