Chapter 2 Diagnostic Algorithms. 4 Traumatic Neck Pain Algorithm

Transcription

1 Chapter 2 Diagnostic Algorithms 4 Traumatic Neck Pain Algorithm

2 Patient presents with a traumatic onset of neck pain. In general, radiographs should be ordered with a history of recent, significant trauma. AP/APOM/lateral views are used to screen for fracture. Oblique views should be included with suspicion of fracture or dislocation; if safe, include flexion/extension views with suspicion of ligament instability. Refer to Diagnostic Imaging History of head trauma. Whiplashtype injury (flexion/ extension). Lateral flexion injury. Re-evaluate cause of cervical complaint. TRAUMATIC NECK PAIN - ALGORITHM Head Trauma Diagnostic Algorithms Stabilize neck and immediate orthopedic / emergency department referral. Patient is unable to: -hold neck up without support, or -has a sense of arm weakness or burning hands Immediate weakness and numbness/tingling in arm. Cervical stinger. Usually benign. If SMT* is used, avoid lateral flexion away from symptomatic side. Radiating pain, numbness/ tingling, or weakness, and examination produces radiation into arms with - cervical compression, shoulder depression, or Valsalva/Soto Hall s, and/or -decrease in deep tendon reflex (DTR) -weakness in specific myotome - sensory loss in a specific dermatome Cervical disc lesion likely. If exacerbated by Tx, refer for medical evaluation. Date revised 6/30/03 Traumatic Neck Pain Algorithm Educational & Patient Care Protocols 1

3 Date revised 6/30/03 n-traumatic Neck Pain Algorithm Page 2 Patient presents with a nontraumatic onset of neck and arm pain. Recurrent bouts of neck and arm pain and/or past history of trauma to neck or head. Positionally related arm numbness/ tingling; neck complaint is secondary. Patient has transient symptoms with other associated neurologic involvement signs/ symptoms. Referral for neurologic evaluation for possible multiple sclerosis or other CNS pathology If no single cause is evident, evaluate as two separate complaints. Look for a peripheral nerve pattern of pain, numbness/tingling, or motor loss. NONTRAUMATIC NECK AND ARM PAIN - ALGORITHM Perform orthopaedic exam and neurologic exam including myotome, dermatome, deep tendon reflex. Any of the following: - specific myotomal weakness - specific dermatomal pattern of hypesthesia - specific hyporeflexia, and/or - radiographic evidence of disc disease, and - reproduction of neck/arm complaint with compression; relief with distraction Foraminal encroachment or cervical disc lesion likely. Order cervical x-rays including oblique views to determine degree of disc height loss, central stenosis, and foraminal encroachment. Perform TOS tests and shoulder stability tests. Neurologic or orthopedic consult. TOS testing positive for reproduction of patient s arm complaints. TOS likely. Conservative trial of care. Proceed to - objective sensory findings - muscle weakness - reflex changes - Compression causes local neck pain only - or minimal radiographic findings of IVF encroachment Facet irritation or other scleratogenous referred pain pattern likely. Shoulder stability testing reproduced patient s arm complaint. Instability likely. If testing is negative, trial of CMT and/or traction for 2 weeks. Educational & Patient Care Protocols 2

4 Date revised 6/30/03 n-traumatic Neck Pain ( Radiation) Page 3 Acute onset of pain with severe global restriction to neck movement and no fever. One or two ROM patterms restricted with local pain on cervical compression. Chronic neck pain and isolated restriction of vertebral motion patterns. Cervical ortho tests positive for local pain; negative for radiating pain. NONTRAUMATIC NECK PAIN (NO RADIATION) - ALGORITHM Positive Kernig s or Brudzinski s. Probable meningitis. Refer immediately to MD. Develops in infancy or childhood. mechanical neck pain management protocol. Active ROM severely restricted while passive ROM is only minimally affected. Acute muscle spasm response to unknown etiology. Probable facet syndrome. Active and passive ROM severely restricted. Investigate chronic postural problems and proceed to management protocol. management protocols. Patient presents with a nontraumatic onset of neck pain (no radiation into arm). Insidious onset associated stiff neck, headache, and fever. Insidious onset of muscle spasm; head fixed in rotation or flexion. Pain on cervical active ROM and palpation of TrPs. Congenital spasmotic torticollis likely. Later onset implies possibility of tumor, infection, or basal ganglion disease. Refer for MRI before proceeding to In adults, proceed to Failure to respond suggests either psychological etiology or dystonia. Refer for psychological or neurological consultation. Re-evaluate cause of cervical complaint. Possibly due to flu or viral infection. Repeat maneuvers. Positive Kernig s or Brudzinski s. 67 Refer for neurologic consult Recheck for fever. Kernig s and/or Brudzinski s positive. management protocols. Refer for neurologic consult Myofascial TrPs probable. Educational & Patient Care Protocols 3

5 Date revised 6/30/03 Reference Consulted Souza, Thomas A. Differential Diagnosis and for the Chiropractor, Protocols and Algorithms, Gaithersburg, MD; Aspen Publisher, Inc Educational & Patient Care Protocols 4