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++

Probability diagnosis

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Vertebral dysfunction, incl. acute torticollis

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Traumatic ‘strain’ or ‘sprain’, incl. ‘whiplash’

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Cervical spondylosis

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Serious disorders not to be missed

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Cardiovascular:

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  • angina

  • subarachnoid haemorrhage

  • arterial dissection

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Neoplasia/cancer:

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  • primary tumour

  • metastasis

  • Pancoast tumour

++

Infection:

++

  • osteomyelitis

  • meningitis

  • atypical infection, e.g. tetanus, leptospirosis

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Vertebral fractures or dislocation

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Pitfalls (often missed)

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Disc prolapse

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Myelopathy

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Cervical lymphadenitis

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Fibromyalgia syndrome

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Outlet compression syndrome (e.g. cervical rib)

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Polymyalgia rheumatica

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Ankylosing spondylitis

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Rheumatoid arthritis

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Oesophageal foreign bodies and tumours

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Paget disease

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Masquerades checklist

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Depression

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Thyroid disorder (thyroiditis)

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Spinal dysfunction

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Is the patient trying to tell me something?

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Highly probable. Stress and adverse occupational factors relevant.

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Key history

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General pain analysis, especially the nature of onset, its site and radiation, and associated features. Past history of neck pain and trauma. Check for presence of radicular pain in arm and paraesthesia or numbness, and for weakness in the arm.

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Key examination

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  • Follow the process for examination of any joint or complex of joints: look, feel, move, measure, test function, look elsewhere and X-ray

  • Three objectives of the examination: reproduce the patient’s symptoms, identify the level of the lesion or lesions, determine the cause (if possible)

  • Perform a neurological examination if radicular pain, weakness or paraesthesia is present in the arm

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Key investigations

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Consider:

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  • FBE

  • ESR

  • rheumatoid arthritis factors

  • radiology can include several modalities but MRI is the investigation of choice for radiculopathy, myelopathy, suspected spinal infection and tumours.

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Imaging should be selected conservatively and plain X-ray is not indicated in the absence of red flags and major trauma.

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Diagnostic tips

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  • The commonest cause of neck pain is idiopathic dysfunction of the facet joints without a history of injury.

  • Strains, sprains and microfractures of the facet joints, especially after a whiplash injury, are difficult to detect and are often overlooked as a cause of persistent pain.

  • ‘One disc—one nerve root’ is a working rule for the cervical spine.

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