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Neck Pain Care Pathway

Date of last update: February, 2024

Diagnosis for Neck Pain with Radiculopathy

(Includes NAD III and 'Specific' Classifications without Red Flags)

Clinical Cornerstone: The goal is to identify the affected nerve root and determine the underlying cause to guide appropriate treatment. Diagnosis involves a thorough history and physical examination, focusing on neurological assessment. Imaging or diagnostic studies (e.g., MRI, electrodiagnostic studies) may be required when persistent, severe, or progressive neurological deficits are present.

  • Definition: Involves the irritation or compression of a nerve root in the cervical spine, manifesting as loss of reflex, weakness, or loss of sensation radiating down the arm, often following a specific nerve distribution. Radicular pain following a specific nerve distribution may be present.

  • Prevalence: Less common than non-specific neck pain (1-6/1000 persons).

  • Risk Factors: Include jobs that require lifting heavy objects, driving, operating vibrating equipment, older age, neck trauma, frequent diving from a board.

  • Pain Location: Typically originates in the neck and radiates down the arm, potentially as far as the hand, often following a specific dermatomal pattern.

  • Duration: Can be acute or chronic, with acute episodes potentially becoming recurrent or chronic if not managed appropriately.

  • Signs and Symptoms:

    • Sharp, shooting, or burning pain radiating down the arm, potentially associated with numbness, tingling, or weakness in the affected limb.

    • Pain may be exacerbated by specific movements such as bending the head forward, lifting, coughing, or sneezing.

  • Physical Examination:

    • Special Tests: Spurlings, Cervical Distraction, Bakody Sign. Positive test can indicate nerve root irritation.

    • Neurological Examination: May reveal sensory deficits, muscle weakness, and altered reflexes in the affected limb, corresponding to the involved nerve root.

    • Neurodynamic Tests: May be utilized to assess nerve root involvement.

    • Imaging: Imaging and advanced imaging can be used to guide alternative treatment options. Indications for imaging in the absence of trauma, suspected myelopathy, or red flags signs / symptoms  include: persistence or worsening of neck pain after four to six weeks of conservative care, progressive neurological symptoms, persistence of profound neurological symptoms after one week of conservative care, identified high-risk ligament laxity populations (e.g. active inflammatory arthritis, congenital disorders).

    • Electrodiagnostic Studies: Electromyography (EMG) and nerve conduction studies can be used to confirm a diagnosis of specific neck pain with radiculopathy. Indications may include persistent, progressive, or profound radiculopathy signs.

  • Response to Conservative Management: Can be variable, with some individuals responding well to conservative interventions like education , manual therapy, exercises , and medication, while others may require more interventional approaches, especially in the presence of persistent or severe neurological deficits.

  • Psychosocial Factors: Important to address psychosocial factors that may impact pain, disability, and recovery, such as fear of movement, beliefs about pain, and emotional well-being, ensuring a comprehensive management approach.

Conduct patient assessment

Red flags present

Red flags present

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Refer to appropriate emergency or healthcare provider

  • Structured patient education

  • Exercise (strength, range of motion)

  • Manual therapies (e.g., spinal manipulation or mobilization, massage)

  • Low-level laser therapy

  • Psychological / social support

  • Medicines

  • Referral

Major symptom/sign change

Goals not achieved

Re-evaluate

Adjust treatment and management plan or refer

References or links to primary sources

  • Bussières A.E, et al. The treatment of neck pain -associated disorders and whiplash-associated disorders: A clinical practice guideline. J Man Phys Ther. 2016; 39(8):P523-564.

 

  • Bussières AE, Taylor JAM, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. Journal of manipulative and physiological therapeutics. 2008;31(1):33-88. doi:10.1016/j.jmpt.2007.11.003

 

  • Berman, Daniel MD; Holtzman, Ari MD; Sharfman, Zachary MD, MS; Tindel, Nathaniel MD. Comparison of Clinical Guidelines for Authorization of MRI in the Evaluation of Neck Pain and Cervical Radiculopathy in the United States. Journal of the American Academy of Orthopaedic Surgeons 31(2):p 64-70, January 15, 2023. | DOI: 10.5435/JAAOS-D-22-00517

 

  • Côté P, et al. Management of neck pain and associated disorders: A clinical practice guidelines from the Ontario Protocol for Traffic Injury (OPTIMa) Collaboration. Eur Spine J. 2016; 28:2000-2022.

 

 

  • Shearer HM, Carroll LJ, Côté P, Randhawa K, Southerst D, Varatharajan S, Wong JJ, Yu H, Sutton D, van der Velde G, Nordin M. The course and factors associated with recovery of whiplash-associated disorders: an updated systematic review by the Ontario protocol for traffic injury management (OPTIMa) collaboration. European Journal of Physiotherapy. 2021 Sep 3;23(5):279-94.

 

  • Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA. 2001;286(15):1841–1848. doi:10.1001/jama.286.15.1841

Contact information for further inquiries or feedback

carolina.cancelliere@ontariotechu.ca

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