• Work Loss Data Institute. Neck and upper back (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Jul 5. 266 p. [315 references]

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Identify Neurologic Findings

• First visit: may be with Primary Care Physician MD/DO (50%), Orthopedist (35%), or Chiropractor (15%)
• Determine Neurologic Findings -- Initial Evaluation

History

• Note any previous neck problems or related disabilities.
• Determine the onset of the injury and mechanism of injury (any direct trauma, head injury, or fall).
• Determine any history of trauma to the neck and any initial acute episode of pain or whiplash injury.
• Search for any symptoms of possible neurologic impairment, such as weakness in an upper extremity, numbness, or radicular pain radiating into upper extremities.
• History of work activities, hobbies, and sports
• Note any psychosocial problems, such as substance abuse, job dissatisfaction, conflict with supervisors, marital problems, and/or financial problems.
• Determine relevant medical history, history of systemic disease, or previous neck injury or disability. Note any history which produces radiating pain in the neck from structures such as the thyroid, the lymph nodes, the esophagus, the trachea, or from a Pancoast tumor in the apex of the lung. Note any history of cancer.

Physical Examination

• Perform a comprehensive examination of the neck and upper extremities including attention to flexibility, strength, and range-of-motion of the neck.
• Perform a careful limited neurological examination of the neck and the upper and lower extremities to determine which diagnostic tests and therapy should be performed. This examination should include reflexes of the biceps, triceps, and brachioradialis tendons and those of the lower extremities, as well as weakness and sensory changes to pin prick by anatomical area (dermatomes) when needed. Check for long tract signs (Babinski and clonus).
• Evaluate for any evidence of weakness or atrophy of muscle groups of the arm.
• Evaluate for any signs of systemic disease.
• Note that any patient with an acute injury and positive neurologic findings requires a neck splint, immobilization, and referral to a spinal surgeon.

Imaging

• Imaging modalities are often not necessary for patients with typical nontraumatic acute neck pain, but due to the risk of treating patients with undiagnosed cervical vertebral fractures, x-rays are necessary if there is any possibility of a fracture, even in patients without neurologic findings. Any patient with a minimal fracture of the cervical spine should have a computed tomography (CT) scan to evaluate the status of the neural arch.
• Indications for x-rays of the cervical spine include the following:
  • A history of direct trauma, blow to the head, any significant whiplash type injury, or any significant fall. These patients should have an x-ray of the cervical spine. Patients with fractures of the cervical spine should be referred to a spinal surgeon.
  • Whiplash with any evidence of neurologic deficit or persistent pain
  • Chronic, slow onset of pain, especially if it is increasing or night pain
  • A history of systemic disease such as cancer, long-term steroid therapy, or alcohol abuse
  • Patients over 50 years of age with any question of etiology of symptoms
  • Patients with significant stiffness of the cervical spine
  • Lateral flexion and extension views may demonstrate instability of the spine and indicate the need for consultation even in the absence of a fracture (fingertip test), muscle atrophy (calf measurement), local areas of tenderness, visual pain analog
• Indications for magnetic resonance imaging (MRI) of the cervical spine include the following:
  • Any suggestion of abnormal neurologic findings below the level of injury
  • Progressive neurologic deficit
  • Persistent unremitting pain with or without positive neurologic findings
  • Previous herniated intervertebral disk within the last two years and radicular pain with positive neurologic findings
  • Patients with significant neurologic findings and failure to respond to conservative therapy despite compliance with the therapeutic regimen
• Imaging procedures such as CT scans are necessary for any fracture of the cervical spine, with referral to a spinal surgeon.
• Additional imaging procedures, such as bone scan, myelography, etc., have special indications and are rarely needed at this stage, unless strong evidence of systemic disease exists and further evaluations thought necessary by the spinal surgeon.
• Other tests such as electromyography (EMG) or nerve conduction studies are not necessary in the initial evaluation of patients with new symptoms, due to the fact that these tests will not become positive until four to six weeks after the onset of symptoms. An EMG is not necessary for the diagnosis of intervertebral disk disease with radiculopathy; rather, its value lies in differentiating other types of neuritis, neuropathy, or muscle abnormalities from radicular neuropathy and for cases where the etiology of the pain is not clear. An EMG is most appropriate to perform after an evaluation by a specialist.

Presumptive Diagnosis (see original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes)

• Without Neurologic Findings
  • Neck pain with no radiation of pain beyond the neck area
  • Neck pain with radiation of pain in shoulders and upper back, but with no radicular signs
  • Chronic neck pain or chronic neck problems or whiplash
• With Neurologic Findings
  • Fracture of cervical spine
  • Radicular pain and positive signs indicate a presumptive diagnosis of herniated intervertebral disk
  • Neurologic signs and symptoms at the cervical level and in the lower body or lower extremities
  • Radicular pain and positive signs indicate a presumptive diagnosis of herniated intervertebral disk and an MRI or CT scan shows positive findings of a herniated intervertebral disk that matches the clinical findings

Cases Without Neurologic Findings (95% of cases)

• Also first visit (day 1):
  • Prescribe decreased activity if necessary based on severity and difficulty of job, passive therapy with heat/ice (3 to 4 times/day), stretching/exercise, appropriate analgesia (i.e., acetaminophen) and/or anti-inflammatory (i.e., ibuprofen) [Benchmark cost: $14], back to work except for severe cases in 72 hours, possibly modified duty. Avoid bed rest.
  • No x-rays unless major trauma (e.g., a fall)
  • If muscle spasms, then prescribe muscle relaxant with limited sedative side effects [Benchmark cost: $44].
  • Reassure patient: common problem (90% of patients recover spontaneously in 4 weeks)

• Second visit (day 3 to 10 – about 1 week after first visit, or sooner, because delayed treatment is not recommended)
  • Document progress (areas of tenderness, motor strength).
  • If still 50% disabled then prescribe manual therapy [Benchmark cost: $250]: Refer to massage therapist, chiropractor, physical therapist, or occupational therapist (3 visits in first week), or by treating DO.
  • Probably discontinue muscle relaxant.

• Third visit (day 10 to 17 – about 1 week after second visit)
  • Document progress.
  • Prescribe muscle-conditioning exercises.
  • At this point 66% to 75% should be back to regular work.
  • If still disabled, then first imaging study (anteroposterior [AP]/lateral 2-view x-ray of upper back) [Benchmark cost: $150] to rule out cervical spondylolysis or joint narrowing/spinal stenosis (age related, not caused by recent trauma - will not change treatment)
  • Continue therapist, change from passive to active modality, 2 visits in next week, teach home exercises
  • End manual therapy (physical therapy or manipulation) at 4 weeks.

• Up to 3 more visits for follow up and documentation of progress

Cases With Neurologic Findings (5% of cases)

• Also first visit (day 1)
  • Same as non-radicular

• Second visit (day 3 to 10 – about 1 week after first visit)
  • Same as non-radicular, but
  • Reassure, but warn of increased numbness or weakness of either arm: if so, get back to provider in one day
  • Consider referral to musculoskeletal physician (orthopedist/physical medicine and rehabilitation (PM&R)/sports medicine)
• Third visit (day 10 to 17 – about 1 week after second visit)
  • Same as non-radicular, but
  • About 50% can be back at modified duty.
  • If improvement, then add strengthening exercises, increased activity
• Fourth visit (day 21 to 28 – about 1 to 2 weeks after third visit)
  • Document, if no improvement then:
  • First MRI (about 3% of total cases, or 30% of cases with neurologic symptoms) to confirm extruded disk with nerve root displacement [Benchmark cost: $1,600]
  • MRI or CT not indicated without obvious clinical level of nerve root dysfunction or before 3 to 4 weeks
  • Consider epidural steroid injection (ESI) for severe cases hoping to avoid surgery [Benchmark cost: $676].
  • Bone scan if spondylolisthesis
  • Second MRI only if progression of neurological symptoms (less than 1% of cases)
  • Refer to fellowship trained Spine Surgeon: Neurosurgeon (50%), Orthopedist (50%)
  • Before surgery, screen for psychological symptoms that could affect surgical outcome (e.g., substance abuse, child abuse, work conflicts, somatization, verbalizations, attorney involvement, smoking).
  • If psychological factors retarding recovery are suspected, possibly refer to psychologist for testing (Minnesota Multiphasic Personality Inventory [MMPI] or, better, Waddell test) [Benchmark cost: $540].

• Surgery (day 28 to 35) (about 2% of total cases, or 20% of radicular cases) (See also "ODG Indications for Surgery™ – Discectomy" in the Procedure Summary of the original guideline document.)
  • Review options/outcomes with patient, let patient decide
  • Simple discectomy/laminectomy, minimally invasive [Benchmark cost: $17,400]
  • Outpatient (23 hour stay)
  • Post-operative pain, walking exercises

• Follow-up visits as required

None provided

During the comprehensive medical literature review, preference was given to high quality systematic reviews, meta-analyses, and clinical trials over the past ten years, plus existing nationally recognized treatment guidelines from the leading specialty societies.

The heart of each Work Loss Data Institute guideline is the Procedure Summary (see the original guideline document), which provides a concise synopsis of effectiveness, if any, of each treatment method based on existing medical evidence. Each summary and subsequent recommendation is hyper-linked into the studies on which they are based, in abstract form, which have been ranked, highlighted and indexed.

• Work Loss Data Institute. Neck and upper back (acute & chronic). Corpus Christi (TX): Work Loss Data Institute; 2007 Jul 5. 266 p. [315 references]

Not applicable: The guideline was not adapted from another source.

2003 (revised 2007 Jul 5)

Work Loss Data Institute - Public For Profit Organization

Not stated

Not stated

There are no conflicts of interest among the guideline development members.

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

This summary was completed by ECRI on February 2, 2004. The information was verified by the guideline developer on February 13, 2004. This NGC summary was updated by ECRI on March 28, 2005, January 13, 2006, April 12, 2006, November 13, 2006, April 2, 2007, and August 28, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.