Neck Pain: A Comprehensive Guide for MCCQE1

Introduction

Neck pain is a ubiquitous presentation in Canadian primary care and emergency departments, with an annual prevalence ranging between 30% and 50%. For the MCCQE1, candidates are expected to differentiate between benign mechanical causes and serious pathologies (e.g., myelopathy, malignancy, infection, fracture) requiring urgent neurosurgical intervention.

This guide focuses on the Medical Expert role within the CanMEDS framework, providing a structured approach to assessment, investigation, and management tailored to Canadian clinical practice guidelines.

MCCQE1 Objectives

When preparing for the MCCQE1, focus on the following key objectives regarding neck pain:

1. Data Acquisition: Obtain a relevant history (onset, trauma, red flags) and perform a focused neurological examination.
2. Problem Solving: Differentiate between mechanical neck pain, radiculopathy, and myelopathy.
3. Management: Apply the Canadian C-Spine Rule to clear the cervical spine in trauma patients.
4. Counseling: Educate patients on the natural history of whiplash and mechanical neck pain (reassurance and early mobilization).

Etiology and Classification

Neck pain can be broadly categorized based on the underlying pathophysiology. Understanding these categories is essential for formulating a differential diagnosis.

Clinical Assessment

1. History Taking (Red Flags)

The primary goal of the history is to rule out “Red Flags” that suggest a serious underlying pathology.

2. Physical Examination

Canadian Guidelines: The Canadian C-Spine Rule (CCR)

The Canadian C-Spine Rule is a mandatory concept for the MCCQE1. It determines which stable trauma patients require diagnostic imaging (X-ray or CT).

Inclusion Criteria: Alert (GCS 15), stable trauma patients with neck pain. Exclusion Criteria: Non-trauma, GCS <15, unstable vitals, age <16 years, paralysis, known vertebral disease, previous C-spine surgery.

The Algorithm

1. High-Risk Factors? (Mandates Imaging)

   • Age $\ge$ 65 years OR
   • Dangerous Mechanism (fall >1m/5 stairs, axial load, high-speed MVA, bicycle collision) OR
   • Paresthesias in extremities.
   • If YES $\rightarrow$ Radiography.

2. Low-Risk Factors? (Allows safe assessment of ROM)

   • Simple rear-end MVA OR
   • Sitting position in ED OR
   • Ambulatory at any time OR
   • Delayed onset of neck pain OR
   • Absence of midline c-spine tenderness.
   • If NO $\rightarrow$ Radiography.

3. Able to Rotate Neck?

   • Actively rotate neck 45° left and right.
   • If UNABLE $\rightarrow$ Radiography.
   • If ABLE $\rightarrow$ No Radiography needed (Clear C-spine).

Investigations

Management Strategies

1. Mechanical Neck Pain / Whiplash

• Education: Reassure patient of good prognosis. “Hurt does not equal harm.”
• Activity: Encourage early mobilization and return to normal activities. Avoid cervical collars (associated with delayed recovery).
• Pharmacotherapy:
  • First line: Acetaminophen or NSAIDs (Naproxen/Ibuprofen).
  • Muscle relaxants (Cyclobenzaprine) for short-term <1 week) use only.
  • Avoid opioids.
• Physiotherapy: Active exercises, range of motion, strengthening.

2. Cervical Radiculopathy

• Conservative: 75-90% resolve without surgery. NSAIDs, physiotherapy, short course of oral corticosteroids (controversial but used).
• Surgical: Indicated for intractable pain, progressive neurological deficit, or failure of conservative management after 6-12 weeks.
  • Procedure: Anterior Cervical Discectomy and Fusion (ACDF) or Posterior Foraminotomy.

3. Cervical Myelopathy

• Urgency: This is a surgical condition.
• Management: Decompressive surgery (ACDF, Laminectomy, or Laminoplasty) to prevent progression. Recovery of lost function is variable; the goal is to halt progression.

Key Points to Remember for MCCQE1

• Myelopathy vs. Radiculopathy: Differentiating these is high-yield. Myelopathy presents with UMN signs (hyperreflexia, Babinski, gait issues), while Radiculopathy presents with LMN signs (specific dermatomal pain, myotomal weakness, hyporeflexia).
• C-Spine Clearance: Always apply the Canadian C-Spine Rule in trauma scenarios.
• Rheumatoid Arthritis: Before surgery (intubation precaution), RA patients need flexion and extension X-rays to rule out atlantoaxial subluxation.
• Imaging: MRI is the imaging of choice for neurologic deficits; CT is the imaging of choice for acute bony trauma.
• Red Flags: Always document the absence of bowel/bladder dysfunction and saddle anesthesia.

Sample Question

Clinical Scenario

A 28-year-old female presents to the Emergency Department following a motor vehicle collision. She was the restrained driver of a sedan that was rear-ended by another vehicle while stopped at a red light. She complains of posterior neck pain and stiffness. She denies loss of consciousness, paresthesias, or weakness in her extremities. On examination, she is alert (GCS 15) and sitting comfortably on the stretcher. There is no midline cervical spine tenderness, but she has tenderness over the paraspinal muscles. She is able to actively rotate her neck 45 degrees to the left and right without significant pain.

Question

According to the Canadian C-Spine Rule, which one of the following is the most appropriate next step in management?

• A. Order a CT scan of the cervical spine
• B. Order a 3-view X-ray series of the cervical spine
• C. Apply a rigid cervical collar and consult Neurosurgery
• D. Clear the cervical spine clinically and discharge with reassurance
• E. Perform flexion and extension X-rays to rule out instability

Explanation

The correct answer is:

• D. Clear the cervical spine clinically and discharge with reassurance

Detailed Explanation: This question tests the application of the Canadian C-Spine Rule (CCR), a crucial guideline for the MCCQE1.

1. High-Risk Factors: The patient is <65 years old, has no paresthesias, and the mechanism (simple rear-end collision) is not dangerous.
2. Low-Risk Factors: She has a simple rear-end collision, is sitting in the ED, and has no midline tenderness. These allow for safe assessment of range of motion.
3. Range of Motion: She is able to actively rotate her neck 45 degrees bilaterally.

According to the CCR, if the patient can rotate their neck, no radiography is required. The C-spine can be cleared clinically.

• Option A & B: Imaging is not indicated because she passes the CCR criteria for clinical clearance.
• Option C: A cervical collar is not indicated and may actually hinder recovery in whiplash-associated disorders; neurosurgery consult is unnecessary.
• Option E: Flexion/extension views are used for suspected ligamentous instability, typically after initial standard imaging or in specific chronic conditions (like RA), not in this acute, low-risk scenario.

References

1. Stiell IG, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841-1848.
2. Choosing Wisely Canada. Imaging for low back pain and neck pain. Link 
3. Toward Optimized Practice (TOP) Guidelines. Management of Neck Pain. Alberta Medical Association.
4. Binder AI. Cervical spondylosis and neck pain. BMJ. 2007;334(7592):527-531.
5. Medical Council of Canada. MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives.