Rather than interviewing the patient in the traditional way, you should have in mind a list of meaningful questions, and your history taking will be more thorough. One way you can develop this list is by picturing the anatomy of the neck.¹ Considering the skin, you would think of herpes zoster and other diagnostic possibilities (Table 1-1 and Figure 1-1) before you begin.² In that way you will ask about
cellulitis, for example. Next, you would picture the muscles and recall contusions and sprains, tension headache, or polymyalgia rheumatica. Then the bones, joints, and ligaments would bring to mind cervical spondylosis, rheumatoid arthritis, a herniated disk, etc. Considering the nerves would prompt the recall of brachial plexus neuropathy, a neuroma, thoracic outlet syndrome, Pancoast tumor, or sympathetic dystrophy. Picturing the meninges would help you recall meningitis, subarachnoid hemorrhage, or meningioma. Picturing the blood vessels would allow you to recall migraine and coronary insufficiency. Do not forget the thyroid gland as this would prompt consideration of subacute thyroiditis.

Onset: In developing the chief complaint, we want to know if the neck pain is acute or chronic. Acute neck pain maybe due to trauma, infection
(meningitis, epidural abscess), or a vascular etiology such as a migraine, subarachnoid hemorrhage, or coronary insufficiency, while chronic neck pain is more likely to be due to a space-occupying lesion (tumor or herniated disk) or a degenerative process such as cervical spondylosis. If the pain began after an injury such as a motor vehicle accident (MVA) or heavy lifting, you need the details. Is there radiation of the pain into the extremities? This would suggest a space-occupying lesion such as tumor, abscess, herniated disk, fracture dislocation, or hematoma. One must not forget the possibility of coronary insufficiency, Pancoast tumor, or thoracic outlet syndrome. Aggravation of the pain on coughing or sneezing would suggest radiculopathy from a herniated disk or other space-occupying lesion.

Is the pain constant or intermittent? Constant pain would be indicative of a space-occupying lesion, tension headache, or cervical sprain whereas intermittent pain would suggest migraine, or coronary insufficiency.

What other symptoms are associated with the pain? Fever or chills would suggest meningitis or epidural abscess. Nausea, vomiting, or photophobia would suggest migraine. Diaphoresis would suggest coronary insufficiency, while numbness, tingling, or weakness in the upper or lower extremities would suggest a herniated disk or other space-occupying lesion.

Review of Systems: In the review of systems, emphasis should be placed on other neurological symptoms such as weakness, paresthesias, gait disturbances, and symptoms of a neurogenic bladder or erectile dysfunction. Also ask about joint pain (gout and rheumatoid arthritis).

Past History: Certainly, we would want to know about previous accidents, surgeries, hospitalizations, or neoplasms that may be subject to metastasis.

Family History: This may be helpful in differentiating coronary insufficiency and migraine. When all is said and done, our history of neck pain is designed to differentiate between those conditions that can be treated conservatively such as cervical sprain and cervical arthritis (cervical
spondylosis, etc.) and more serious conditions such as a herniated disk and other space-occupying lesions that may require surgical intervention; our physical findings will be even more helpful in this regard.

Your primary objective in examining a patient with neck pain is to rule out cervical radiculopathy or myelopathy and serious conditions that may cause radiation of pain to the neck such as coronary insufficiency, cholecystitis, and a subdiaphragmatic abscess. In acute cases, you must also consider the possibility of meningitis and subarachnoid hemorrhage. The author can vividly recall a case of acute neck pain that he diagnosed as a subarachnoid hemorrhage simply because he tested for nuchal rigidity. That same patient had been given the diagnosis of migraine when she visited the emergency room 24 hours before.

Your examination begins by examining for a spastic or ataxic gait (Figure 1-2).

Next, perform a Romberg test (Figure 1-3), which will also help rule out myelopathy. Palpate the muscles of the neck for spasm and trigger points (Figure 1-4), which can assist you in diagnosing tension headaches and cervical sprains. Palpate the cervical nerve roots (Figure 1-5) for tenderness, a sign of radiculopathy or brachial plexus neuralgia. Examine the pupils for Horner syndrome, a sign of thoracic outlet syndrome.

Next, test for the range of motion (Figures 1-6 and 1-7), which is normally at 30 degrees of extension, 60 degrees of flexion, and 45 degrees of lateral bending right and left. Limitation of flexion may indicate nuchal rigidity as well as cervical disk herniation, while limitation of extension will be suggestive of cervical spondylosis or ligamentum flavum syndrome. Extension of the neck in the latter condition also causes tingling in the lumbar spine and legs called Lhermitte sign. Limitation of range of motion in all directions is typical of cervical spondylosis or fractures in older patients and fracture in younger patients.

Perform a cervical compression test (Figure 1-8) by applying pressure to the top of the head. If there is radiculopathy, this will cause radiation of






pain into one or both upper extremities. The same radiation results when you perform Spurling test (Figure 1-9). This is done by extension, lateral flexion, and rotation of the neck to the right or left and again applying moderate pressure to the top of the head.

Perform Adson tests (Figure 1-10) to rule out thoracic outlet syndrome. This is done by checking the pulse and pressing on the ipsilateral shoulder, while at the same time turning the patient’s head to the same or opposite side and having the patient take a deep breath and hold it. If the pulse is diminished, you have made the diagnosis (more about this later in the case histories).

Now, to rule out cervical radiculopathy, check the power (Figures 1-11 and 1-12), reflexes (Figure 1-13), and sensation (Figure 1-14) in the upper extremities. If one or more of these modalities is asymmetrically diminished, you should suspect radiculopathy or neuropathy. For neurologic findings in the most common forms of cervical radiculopathy, see Table 1-2.