• 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.

Work-related disorders of the neck and upper back

Diagnosis
Evaluation
Management
Treatment

Chiropractic
Family Practice
Internal Medicine
Neurological Surgery
Neurology
Physical Medicine and Rehabilitation

Advanced Practice Nurses
Health Care Providers
Health Plans
Nurses
Physician Assistants
Physicians

To offer evidence-based step-by-step decision protocols for the assessment and treatment of workers' compensation conditions

Workers with occupational disorders of the neck and upper back

The following interventions/procedures were considered and recommended as indicated in the original guideline document:

1. Activity restrictions/work modifications
2. Back schools for treatment
3. Bone scan
4. Botulinum toxin (injection) for cervical dystonia
5. Cervical strengthening exercises
6. Chiropractic care/manipulation
7. Cognitive behavioral rehabilitation for chronic cases
8. Cold packs
9. Corpectomy and stabilization
10. Decompression (for patients with severe or progressive myelopathy)
11. Discectomy/laminectomy/laminoplasty/laminotomy
12. Electromyography (EMG) (needle, not surface), including H-reflex tests
13. Epidural steroid injection (ESI) for radicular pain
14. Evoked potential studies in diagnostic assessment
15. Exercise
16. Facet join pain (evaluation of signs and symptoms)
17. Facet joint diagnostic blocks
18. Fear-avoidance beliefs questionnaire (FABQ) in patient selection for physical therapy
19. Fluoroscopy (for ESIs)
20. Functional restoration programs
21. Fusion, anterior cervical
22. H-reflex tests
23. Headache screening for neck injury
24. Heat/cold applications
25. Home health services
26. Home cervical autotraction (patient controlled) devices
27. Massage
28. Methylprednisolone (high-dose) for whiplash
29. Muscle relaxants in acute cases
30. Nonprescription medications (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs])
31. Physical therapy/occupational therapy
32. Pillow as a neck support while sleeping
33. Psychological screening prior to surgery
34. Return to work
35. Sensory evoked potentials (SEPS) for unexplained myelopathy and/or in unconscious spinal cord injury patients
36. Steroids (in acute spinal cord injury)
37. Stretching as part of an exercise program
38. Surgery (See original guideline document for specific types of surgery)
39. Therapeutic exercises
40. Whiplash associated disorder (WAD) treatment
41. Work conditioning/hardening

The following interventions/procedures are under study and are not specifically recommended:

1. Acupuncture for upper back
2. Back brace, post-operative (fusion)
3. Bone growth stimulators
4. Electromagnetic therapy (PEMT)
5. Ergonomics
6. Facet joint radiofrequency neurotomy/facet rhizotomy
7. Fusion, posterior cervical
8. Greater occipital nerve block (diagnostic and therapeutic)
9. Multidisciplinary biopsychosocial rehabilitation
10. Patient education
11. Percutaneous electrical nerve stimulation (PENS)
12. Plate fixation, cervical spine surgery
13. Therapeutic ultrasound

The following interventions were considered, but are not recommended:

1. Acupuncture for neck pain
2. Bed rest
3. Biofeedback
4. Cervical orthosis
5. Cervical collars, including soft collars
6. Chymopapain (injection)
7. Computed tomography (CT) (Not recommended except for specific indications [See original guideline document])
8. Current perception threshold (CPT) testing
9. Delayed treatment
10. Diagnostic ultrasound
11. Diathermy
12. Discography
13. Disc prosthesis
14. Electrical muscle stimulation (EMS)
15. Electrotherapies
16. Facet-joint therapeutic steroid injections
17. Flexibility/range of motion evaluations
18. F-wave tests
19. Galvanic current
20. Hospitalization
21. Iontophoresis
22. Laser therapy
23. Magnetic resonance imaging (Not recommended except for specific indications [See original guideline document])
24. Magnets
25. Manipulations under anesthesia (MUA)
26. Myelography (Not recommended except for surgical planning)
27. NC-stat nerve conduction studies/nerve conduction studies (NCS)
28. Opioids (Not recommended except for short use in severe cases)
29. Oral corticosteroids
30. Percutaneous neuromodulation therapy (PNT)
31. Prolotherapy (sclerotherapy)
32. Radiography (Not recommended except for specific indications [See original guideline document])
33. Rest
34. Sensory evoked potentials (SEPS) for radiculopathies and peripheral nerve lesions
35. Standing MRI
36. Surface electromyography (EMG)
37. Thermography (diagnostic)
38. Transcutaneous electrical neurostimulation (TENS)
39. Transplantation, intervertebral disc
40. Trigger point injections
41. Videofluoroscopy (for range of motion)

• Diagnostic value of tests
• Effectiveness of treatments for relieving pain and restoring normal function

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

Work Loss Data Institute (WLDI) conducted a comprehensive medical literature review (now ongoing) with preference given to high quality systematic reviews, meta-analyses, and clinical trials published since 1993, plus existing nationally recognized treatment guidelines from the leading specialty societies. WLDI primarily searched MEDLINE and the Cochrane Library. In addition, WLDI also reviewed other relevant treatment guidelines, including those in the National Guideline Clearinghouse, as well as state guidelines and proprietary guidelines maintained in the WLDI guideline library. These guidelines were also used to suggest references or search terms that may otherwise have been missed. In addition, WLDI also searched other databases, including MD Consult, eMedicine, CINAHL, and conference proceedings in occupational health (i.e. American College of Occupational and Environmental medicine [ACOEM]) and disability evaluation (i.e. American Academy of Disability Evaluating Physicians [AADEP], American Board of Independent Medical Examiners [ABIME]). Search terms and questions were diagnosis, treatment, symptom, sign, and/or body-part driven, generated based on new or previously indexed existing evidence, treatment parameters and experience.

In searching the medical literature, answers to the following questions were sought: (1) If the diagnostic criteria for a given condition have changed since 1993, what are the new diagnostic criteria? (2) What occupational exposures or activities are associated causally with the condition? (3) What are the most effective methods and approaches for the early identification and diagnosis of the condition? (4) What historical information, clinical examination findings or ancillary test results (such as laboratory or x-ray studies) are of value in determining whether a condition was caused by the patient's employment? (5) What are the most effective methods and approaches for treating the condition? (6) What are the specific indications, if any, for surgery as a means of treating the condition? (7) What are the relative benefits and harms of the various surgical and non-surgical interventions that may be used to treat the condition?  (8) What is the relationship, if any, between a patient's age, gender, socioeconomic status and/or racial or ethnic grouping and specific treatment outcomes for the condition? (9) What instruments or techniques, if any, accurately assess functional limitations in an individual with the condition? (10) What is the natural history of the disorder? (11) Prior to treatment, what are the typical functional limitations for an individual with the condition? (12) Following treatment, what are the typical functional limitations for an individual with the condition? (13) Following treatment, what are the most cost-effective methods for preventing the recurrence of signs or symptoms of the condition, and how does this vary depending upon patient-specific matters such as underlying health problems?

Criteria for Selecting the Evidence

Preference was given to evidence that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reports a cohort study, whether prospective or retrospective, or (5) The article reports a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

More information about the selection of evidence is available in "Appendix. ODG Treatment in Workers' Comp. Methodology description using the AGREE instrument" (see "Availability of Companion Documents" field).

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Review of Published Meta-Analyses
Systematic Review

The Work Loss Data Institute (WLDI) reviewed each article that was relevant to answering the question at issue, with priority given to those that met the following criteria: (1) The article was written in the English language, and the article had any of the following attributes: (2) It was a systematic review of the relevant medical literature, or (3) The article reported a controlled trial – randomized or controlled, or (4) The article reported a cohort study, whether prospective or retrospective, or (5) The article reported a case control series involving at least 25 subjects, in which the assessment of outcome was determined by a person or entity independent from the persons or institution that performed the intervention the outcome of which is being assessed.

Especially when articles on a specific topic that met the above criteria were limited in number and quality, WLDI also reviewed other articles that did not meet the above criteria, but all evidence was ranked alphanumerically (see the Rating Scheme of the Strength of Evidence field) so that the quality of evidence could be clearly determined when making decisions about what to recommend in the Guidelines. Articles with a Ranking by Type of Evidence of Case Reports and Case Series were not used in the evidence base for the Guidelines. These articles were not included because of their low quality (i.e., they tend to be anecdotal descriptions of what happened with no attempt to control for variables that might effect outcome). Not all the evidence provided by WLDI was eventually listed in the bibliography of the published Guidelines. Only the higher quality references were listed. The criteria for inclusion was a final ranking of 1a to 4b (the original inclusion criteria suggested the methodology subgroup), or if the Ranking by Type of Evidence was 5 to 10, the quality ranking should be an "a."

Not stated

Not applicable

The guideline developers reviewed published cost analyses.

External Peer Review

Prior to publication, select organizations and individuals making up a cross-section of medical specialties and typical end-users externally reviewed the guideline.

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.

These guidelines unite evidence-based protocols for medical treatment with normative expectations for disability duration. They also bridge the interests of the many professional groups involved in diagnosing and treating work-related disorders of the neck and upper back.

• Adverse reactions to chiropractic care for neck pain may be common and they appear more likely to follow cervical spine manipulation than mobilization. Data suggest that spinal manipulation is associated with frequent, mild and transient adverse effects as well as with serious complications that can lead to permanent disability or death.
• Risks of adverse effects from surgery. Research has indicated that as many as 60% of patients who received laminoplasty had posterior neck and shoulder girdle pain post-operatively (versus 25% in the laminectomy group). Resection of posterior osteophytes during decompression for progressive myelopathy may be associated with increased risk of injury to the spinal cord, and a potential side effect of removal of the posterior longitudinal ligament is the risk of cord contusion.
• There have been recent case reports of cerebellar infarct and brainstem herniation as well as spinal cord infarction after cervical transforaminal injection. Quadriparesis with a cervical epidural steroid injection (ESI) at C6-7 has also been noted and the American Society of Anesthesiologists Closed Claims Project database revealed 9 deaths or cases of brain injury after cervical ESI.
• Muscle relaxants have potential side effects, including drowsiness in up to 30 percent of patients.

Patients undergoing occipitocervical fusion or C1–2 (high cervical region) fusion is an absolute contraindication for returning to any type of activity with a risk of re-injury (such as contact sports), because the C-1 arch is relatively fragile and stability depends on the status of the periodontoid ligaments.

The Treatment Planning sections outline the most common pathways to recovery, but there is no single approach that is right for every patient and these protocols do not mention every treatment that may be recommended. See the Procedure Summaries (in the original guideline document) for complete lists of the various options that may be available, along with links to the medical evidence.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness
Timeliness

• 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.