The guidelines provided by the New York State Workers Compensation Board are designed to assist healthcare professionals in managing individuals with Neck Injuries. These directives aim to support physicians and healthcare practitioners in determining the appropriate treatment and care for individuals experiencing neck-related health issues.
Healthcare professionals specializing in Neck Injuries can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable approaches for their patients.
It is crucial to emphasize that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding the management of Neck Injuries should involve collaboration between the patient and their healthcare provider.
History Taking and Physical Examination
Gathering the patient’s history and conducting a physical examination lay the groundwork for deciding what comes next in terms of diagnosis and treatment. If there’s a discrepancy between the results of clinical evaluations and other diagnostic procedures, the objective clinical findings should be given more importance. The medical records should adequately detail the following:
History of Present Injury
When assessing and treating an injury, it’s crucial to gather a detailed history, ideally taken close to the time of the incident. This history should cover various aspects, including:
- Mechanism of Injury: Details about how the symptoms started and progressed, offering a thorough account of the incident and the body’s position throughout.
- Location of Pain and Symptom Nature: Understanding where it hurts, the nature of symptoms, and factors that worsen or alleviate them, such as specific sleep positions. It’s noteworthy whether raising the arm over the head provides relief from radicular-type symptoms. The history should encompass primary and secondary complaints, like neck pain, arm pain, headaches, and shoulder girdle issues.
- Pain Assessment Tool: Using a recognized tool like the Visual Analog Scale (VAS) is highly recommended, especially in the initial two weeks post-injury. This ensures a comprehensive approach to addressing all work-related symptoms, including pain.
- Presence and Distribution of Symptoms: Checking for upper and/or lower extremity numbness, tingling, or weakness is crucial, especially if these symptoms are triggered or intensified by actions like coughing or sneezing.
- Changes in Bowel, Bladder, or Sexual Function: Any alterations in these functions should be noted.
- Loss or Impairment of Fine Motor Skills: Difficulty in manipulating small objects or experiencing a decline in fine motor skills is a significant aspect to explore.
- Prior Injuries to the Same Area: Understanding any previous occupational or non-occupational injuries to the same area, including the treatments undergone, history of motor vehicle accidents, chronic symptoms, recurrent issues, and any existing functional limitations. Reviewing past spinal imaging studies is also crucial.
- Emotional and/or Psychological Reactions: A thorough history should include any emotional or psychological responses to the current injury or illness.
- Ability to Perform Job Duties and Daily Activities: Assessing how well the individual can carry out their job responsibilities and handle daily activities is fundamental to understanding the impact of the injury.
Past History
To get a complete picture, it’s crucial to dive into:
- Comprehensive Past Medical and Surgical History: Understanding the patient’s medical and surgical background provides valuable context.
- Review of Systems: A systematic exploration of various bodily systems, including constitutional symptoms, eyes, ears, nose, mouth, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary/breast, neurological, psychiatric, endocrine, hematologic/lymphatic, and allergic/immunologic. The depth and focus can be tailored case by case based on the specific condition under consideration and clinical judgment.
- Smoking History: An inquiry into the patient’s history of smoking.
- Vocational and Recreational Pursuits: Understanding the patient’s work and recreational activities.
- History of Depression, Anxiety, or Psychiatric Illness: Exploring any previous experiences with mental health issues.
- History of Cervical Injuries or Injuries to the Upper Extremities: Investigating any past incidents involving the cervical region, shoulder, arm, forearm, or wrist/hand.
- History of Brachial Plexus or Peripheral Nerve Issues: Identifying any history of injury or disease affecting the brachial plexus or peripheral nerves in the upper extremity.
- Difficulty Walking or Loss of Balance: Evaluating any challenges with walking or balance issues.
Physical Examination
The examination should encompass recognized tests and techniques relevant to the area under scrutiny, incorporating:
- Visual Inspection, Including Posture: A thorough visual assessment, considering posture.
- Cervical Range of Motion: Evaluating the range and quality of motion in the cervical region, taking note of muscle spasms. Specific joint motion assessments may be necessary. However, in cases of acute trauma, assessing range of motion should be deferred until ruling out fractures and instability.
- Examination of the Cervical Spine: This includes an examination of the atlanto-occipital articulation, considering upward and downward gaze.
- Palpation: Palpating spinous processes, facets, and muscles to identify myofascial tightness, tenderness, and trigger points.
- Motor and Sensory Examination: Assessing the upper muscle groups with a focus on specific nerve roots, along with testing sensation to light touch, pinprick, temperature, position, and vibration. A difference of more than 2 cm in circumferential measurements between the two upper extremities may suggest chronic muscle wasting.
- Deep Tendon Reflexes: Evaluating reflexes, where asymmetry may indicate pathology. Inverted reflexes, like arm flexion or triceps tap, could signal nerve root or spinal cord issues at the tested level. Pathologic reflexes, including upper and/or lower extremity clonus, grasp reflex, Babinski response, and Hoffman’s sign, should also be considered.
Relationship to Work
This involves providing an assessment of the likelihood that the illness or injury is connected to work. If additional details are needed to establish this work-related connection, the physician should explicitly specify the required additional diagnostic studies or job-related information.
Spinal Cord Evaluation
In situations where the mechanism of injury, historical account, or clinical presentation suggests a potential severe injury, an additional evaluation is warranted. A comprehensive neurological examination for potential spinal cord injury may encompass:
- Sharp and Light Touch, Deep Pressure, Temperature, and Proprioceptive Sensory Function
- Strength Testing
- Assessment of Anal Sphincter Tone and/or Perianal Sensation
- Evaluation for the Presence of Pathological Reflexes in the Upper and Lower Extremities
- Identification of Evidence Indicative of an Incomplete Spinal Cord Injury Syndrome:
- Anterior Cord Syndrome: This syndrome manifests as the loss of motor function and perception of pain and temperature below the level of the lesion, while touch, vibration, and proprioception remain intact. Typically observed after a significant compressive or flexion injury, emergent CT or MRI is essential to identify a potentially reversible compressive lesion requiring immediate surgical intervention. The prognosis for recovery is considered the most challenging among incomplete syndromes.
- Brown-Sequard Syndrome: Characterized by ipsilateral motor weakness and proprioceptive disturbance, coupled with contralateral alterations in pain and temperature perception.
Brown-Sequard Syndrome is identified by ipsilateral motor weakness and proprioceptive disturbance, coupled with contralateral alterations in pain and temperature perception below the level of the lesion. This manifestation is commonly associated with penetrating trauma or lateral mass fractures. While surgery is not specifically mandated, debridement of an open wound may be considered.
Central Cord Syndrome is marked by sensory and motor disturbances affecting all limbs, with the upper extremities often more affected than the lower ones. Additionally, there is a loss of bowel and bladder function while perianal sensation remains intact. This syndrome is typically observed in older patients with spinal stenosis and a rigid spine following hyperextension injuries. Surgical intervention is generally not deemed necessary.
Posterior Cord Syndrome, a rare condition, is characterized by the loss of sensation below the level of the injury but retains intact motor function.
Soft Tissue Injury Evaluation
Soft tissue injuries encompass trauma to the muscles, ligaments, tendons, and connective tissue. The predominant cause often involves the sudden hyperextension and/or hyperflexion of the neck. Syndromes may also arise from acceleration/deceleration on the lateral plane. Notably, a genuine isolated cervical strain does not manifest with focal neurological symptoms. Soft tissue injuries comprise conditions like cervical strain, myofascial syndromes, and somatic dysfunction. The Quebec Classification of Whiplash-Associated Disorders provides a framework for categorizing both mild and more severe cervical injuries:
- Grade I: Neck complaints involving pain, stiffness, or tenderness only, lacking physical signs. The lesion is not severe enough to induce muscle spasm. Examples include whiplash injury, minor cervical sprains, or strains.
- Grade II: Neck complaints accompanied by musculoskeletal signs, such as limited range of motion. This grade encompasses muscle spasm related to soft tissue injury, whiplash, cervical sprain, and cervicalgia with headaches, as well as sprained cervical facet joints and ligaments.
- Grade III: Neck complaints, including limited range of motion, combined with neurological signs. Conditions falling under this grade comprise whiplash, cervicobrachialgia, herniated disc, and cervicalgia with headaches.
- Grade IV: Neck complaints involving a fracture or dislocation.
