Neck Pain

Introduction

Neck pain is a common presenting complaint in Canadian primary care settings. As future physicians preparing for the MCCQE1, it's crucial to understand the etiology, diagnosis, and management of neck pain within the Canadian healthcare context. This guide will help you navigate the complexities of neck pain, aligning with MCCQE1 objectives and the CanMEDS framework.

Epidemiology in the Canadian Context

• Prevalence: Approximately 15-20% of Canadian adults experience neck pain at any given time
• Incidence: Annual incidence in Canada is estimated at 14.6%
• Risk factors specific to Canadian population:
  • Sedentary lifestyle (increased screen time)
  • Cold climate (muscle tension)
  • Occupational factors (office work, manual labor)

Etiology and Classification

Understanding the causes of neck pain is crucial for accurate diagnosis and management. For MCCQE1 preparation, focus on the following classification:

Clinical Presentation and Assessment

When assessing a patient with neck pain, consider the following steps aligned with the CanMEDS Medical Expert role:

Diagnostic Imaging

In the Canadian healthcare system, judicious use of diagnostic imaging is emphasized to reduce unnecessary costs and radiation exposure. Follow these guidelines:

1. X-rays: Indicated for trauma, suspected instability, or when red flags are present
2. CT scan: Useful for detailed bony anatomy, especially in trauma cases
3. MRI: Reserved for suspected disc herniation, myelopathy, or when neurological symptoms persist

Management

Treatment of neck pain in Canada follows a stepwise approach, emphasizing conservative measures before invasive interventions:

Canadian Guidelines for Neck Pain Management

The Canadian Chiropractic Guideline Initiative (CCGI) provides evidence-based recommendations for the management of neck pain:

1. Encourage self-management and physical activity
2. Consider multimodal care (exercise + mobilization/manipulation)
3. Offer structured patient education
4. Use low-level laser therapy or intermittent mechanical traction for short-term pain relief
5. Avoid collar use for whiplash-associated disorders

Key Points to Remember for MCCQE1

• Understand the epidemiology of neck pain in the Canadian population
• Know the red flags that warrant immediate investigation (e.g., fever, neurological deficits)
• Be familiar with the Choosing Wisely Canada recommendations for imaging
• Recognize the stepwise approach to management, emphasizing conservative measures
• Understand the role of interdisciplinary care in neck pain management (CanMEDS Collaborator role)
• Be aware of Canadian-specific guidelines for neck pain treatment

Sample Question

A 45-year-old woman presents to her family physician with a 3-week history of neck pain. She denies any trauma or radicular symptoms. Physical examination reveals decreased range of motion and tenderness over the cervical paraspinal muscles. There are no neurological deficits. Which one of the following is the most appropriate next step in management?

• A. Order cervical spine X-rays
• B. Prescribe a soft cervical collar
• C. Refer for immediate physiotherapy
• D. Recommend over-the-counter NSAIDs and provide education on self-management
• E. Order an MRI of the cervical spine

Explanation

The correct answer is:

• D. Recommend over-the-counter NSAIDs and provide education on self-management

This answer aligns with Canadian guidelines for managing acute neck pain without red flags. The patient's presentation suggests uncomplicated mechanical neck pain. According to Choosing Wisely Canada and the Canadian Chiropractic Guideline Initiative:

1. Imaging is not recommended for uncomplicated neck pain within the first 6 weeks (eliminating options A and E)
2. Soft cervical collars are not recommended, especially for non-traumatic neck pain (eliminating option B)
3. While physiotherapy can be beneficial, immediate referral is not necessary as the first step (eliminating option C)
4. Conservative management with NSAIDs and patient education on self-management is the most appropriate initial approach in this scenario

This question tests your knowledge of Canadian guidelines and the principle of starting with conservative management for uncomplicated neck pain.

References

1. Côté P, Wong JJ, Sutton D, et al. Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016;25(7):2000-2022.

2. Choosing Wisely Canada. Imaging Tests for Lower Back Pain: When you need them and when you don't. https://choosingwiselycanada.org/imaging-tests-low-back-pain/ (opens in a new tab)

3. Canadian Chiropractic Guideline Initiative. Clinical Practice Guideline for the Management of Neck Pain and Associated Disorders. https://www.chiropractic.ca/guidelines-best-practice/ (opens in a new tab)

4. Bussieres AE, Stewart G, Al-Zoubi F, et al. The Treatment of Neck Pain-Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. J Manipulative Physiol Ther. 2016;39(8):523-564.e27.

5. Hoy DG, Protani M, De R, Buchbinder R. The epidemiology of neck pain. Best Pract Res Clin Rheumatol. 2010;24(6):783-792.