“I need a plain x-ray to look for Cervical Spondylosis”EVERYONE gets cervical spondylosis as they get older – like grey hair. There is poor correlation between radiological ‘age-related’ changes and neck pain. Doing a plain cervical x-ray on someone with neck pain and telling them they have cervical spondylosis/arthritis/”wear and tear” may be harmful /reduce the effectiveness of physio. Plain X-ray only indicated if red flags.
“I need an MR Cervical Spine to manage this patient” We often are asked for MR Cervical Spine to ‘show the cause’ of someone’s pain or because a physiotherapist has suggested it. MR C-spine is rarely helpful: a) because usually it is muscular pain with radiation not radiculopathy; b) cervical radiculopathy usually improves with conservative treatment; c) neurosurgery is rarely offered/has little evidence base in this area. MR C-Spine is not available open access in NHS Lothian . We request it mainly to look for spinal cord pathology.
“Nerve conduction studies may be helpful” Usually neck and arm pain is not radicular. We do not arrange nerve conduction studies in patients with ulnar nerve sensory symptoms. Carpal tunnel syndrome should go to the hand clinic first.
• Patients with neck and arm pain and associated neurological symptoms make up a substantial number of referrals to medical neurology in NHS Lothian • Most patients with these symptoms may be better managed in primary care or secondary care services other than neurology.
Consider red flags (see below) Conservative treatment with physiotherapyreferral and analgesia. Consider referral to Musculoskeletal Services or Chronic Pain Services. Sensory symptoms mainly in the hand and forearm often dont conform to textbook distributions are usually Carpal Tunnel Syndrome and/or Ulnar nerve irritation. “NHS choices –Neck Pain” has useful links to neck exercise videos
NECK AND ARM PAINNO DEFINITE NEUROLOGICAL SIGNS
RARELY INDICATED
Muscular painCervical Radiculopathy (rarely)
NECK AND ARM PAIN NEUROLOGICAL SYMPTOMS AND SIGNS
MAY OFTEN BE AVOIDED
Muscular pain combined with • Carpal Tunnel Syndrome • Ulnar Nerve Irritation • Non specific sensory disturbance Cervical Radiculopathy (rarely) Other causes rare– e.g. brachial neuritis
HAND PARAESTHESIA WITH OR WITHOUT PAIN
MAY OFTEN BE AVOIDED
Carpal Tunnel Syndrome (often whole hand tingling)
Trial of wrist splints at night for 3 months prior to Hand Clinic referral.
Ulnar Nerve Symptoms (4th and 5th fingers)
Advise avoid pressure/prolonged flexion elbow. Rarely requires referral to Neurology, investigation or treatment –see neurodiagnosis.org
Other
Consider Neurology referral.
RED FLAGS include:
Systemic upset (weight loss, night sweats, fevers); Signs of spinal cord compression (e.g. gait disturbance, clumsy or weak hands, loss of sexual, Lhermitte’s phenomenon, bladder or bowel dysfunction); Significant preceding trauma or neck surgery; History of TB, HIV, cancer or inflammatory arthritis
