Unilateral Neck Pain Research Articles

Angioedema and Pharyngeal Pain: Unusual Presentation of Internal Carotid Dissection

Cervical artery dissections are the most common cause for nonatherosclerotic vasculopathies in young adults who present with stroke. They occur most often between the ages of 35 and 50 years with a peak in the fifth decade of life. Community-based studies have shown the annual incidence in the United States to range from 2.5-3.0 per 100,000. The importance of recognizing presentations of carotid artery dissections help to identify and treat patients. Common signs include unilateral head, face, or neck pain with Horner’s syndrome, cranial nerve palsies, or pulsatile tinnitus. These may be preceded by minor trauma that is noted upon further history. Here we impart an unusual presentation of internal carotid artery (ICA) dissection mimicking angioedema with unilateral tongue swelling and associated pharyngeal pain.

Carotidynia: Revisiting an Unfamiliar Entity

Carotidynia (unilateral neck pain reproducible with light pressure on the carotid artery) is a controversial and poorly understood vascular condition. This review provides important historical information, several representative case reports, and a comprehensive summary of the literature. The authors also propose an algorithm for the care of these patients.

Transoral Robotic Surgery: A Novel Technique to Treat Eagle Syndrome

Objective: 1) Report a novel surgical approach to perform a styloidectomy for Eagle syndrome. 2) Propose a new indication for transoral robotic surgery.3) Demonstrate improved exposure and visualization of a skull base region where critical neurovascular structures are at risk. Method: We report a case from 2010 of a 47-year-old woman presenting with unilateral vocal cord dysfunction, neck pain, throat pain, dysphagia, and odynophagia. Her symptoms, beginning after neck trauma, fluctuated with neck positioning. The diagnosis of Eagle syndrome was confirmed by CT, and a transoral robotic styloidectomy was performed. Results: When conservative management failed to improve the patient’s symptoms, a transoral robotic-assisted tonsillectomy, pharyngoplasty, and styloidectomy of her elongated right styloid process were successfully performed with the da Vinci surgical robot. Postoperatively the patient recovered well and reported significant improvement of her symptoms. To the authors’ knowledge a transoral robotic styloidectomy for Eagle syndrome has never before been described. The improved exposure and magnified visualization achieved with the transoral robotic approach represents a significant advent in a skull base procedure in which several critical neurovascular structures are at risk. Conclusion: Eagle syndrome is a rare diagnosis of unilateral lower cranial neuropathy (IX, X) secondary to irritation from an elongated styloid process. Traditionally transoral and transcervical styloidectomy procedures are performed. We propose that transoral robotic surgery provides improved visualization and exposure of a surgically high-risk region of the skull base.

Guillain–Barré syndrome variant with prominent facial diplegia, limb paresthesia, and brisk reflexes

Dear Sirs, Guillain-Barresyndrome (GBS) is an acute monophasic neuropathic disorder of autoimmune origin. Rare GBS variants have been described, including Fisher's syndrome (2) and subtypes that present predominantly with lower cranial nerve involvement or pure brachio-pharyngeal weakness (10). Another condition that has been suggested to be part of the GBS spectrum is characterized by prom- inent facial diplegia and limb paresthesia with no or only mild motor deficits. This condition was first outlined by Ropper on the basis of four cases (7) and characterized in more detail by Susuki and colleagues in a recent issue of this journal (9). We report here a patient who presented initially with unilateral Bell's palsy, brisk tendon reflexes, and normal CSF examination, who subsequently developed the full clinical picture of the syndrome described by Ropper and Susuki including bilateral facial paresis, limb paresthesia, and albuminocytologic dissociation. Notably, our patient did not respond to corticosteroid treatment but symptoms resolved rapidly upon treatment with IVIg. A 33-year-old man presented with facial muscle weak- ness on the right side. Symptoms had started 3 days earlier with unilateral right neck pain and were accompanied by slight paresthesia in the limbs. The pain resolved, but the other symptoms progressed over the next 72 h. Anteceding gastrointestinal or airway infection were denied.

Is it time to discard the term “diagnosis” when examining a person with uncomplicated axial neck pain?

<h3>COMMENTARY ON</h3> Fryer G, Adams JH. Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: a prospective case series. Spine J 2011;11:171–6 (<i>in this issue</i>).

Lower Trapezius Muscle Strength in Individuals With Unilateral Neck Pain

Descriptive and within-subject comparative study. To examine lower trapezius muscle strength in individuals with unilateral neck pain. Previous research has established the presence of reduced cervical flexor, extensor, and rotator muscle strength in individuals with neck pain. Some authors have suggested that individuals with neck pain have limited strength of the lower trapezius muscle, yet no research has investigated this claim. Twenty-five individuals with unilateral neck pain participated in this study. Participants completed the Northwick Park Neck Pain Questionnaire (NPQ) as a measure of disability. Side of neck pain, duration of neck pain, and hand dominance were recorded. Lower trapezius muscle strength was assessed bilaterally in each participant, using a handheld dynamometer. A significant difference in lower trapezius strength was found between sides (P<.001), with participants demonstrating an average of 3.9 N less force on the side of neck pain. The tested levels of association between NPQ score and percent strength deficit (r = -0.31, P = .13), and between symptom duration and percent strength deficit (r = -0.25, P = .22), were not statistically significant. No significant association was found between hand dominance and side of stronger lower trapezius (P = .59). The results of this study demonstrate that individuals with unilateral neck pain exhibit significantly less lower trapezius strength on the side of neck pain compared to the contralateral side. This study suggests a possible association between lower trapezius muscle weakness and neck pain.

Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: a prospective case series

Background context Zygapophyseal joint injury and inflammation have been proposed as causes of acute benign spinal pain, but this etiology has not been investigated. Purpose To investigate the presence of periarticular tissue inflammation and zygapophysial joint synovitis in the cervical region using magnetic resonance imaging (MRI) in subjects with acute unilateral cervical pain and limited motion (acute “crick in the neck” <48 hours from onset), as well as the feasibility of recruiting these subjects. Study design/setting Three-month case series in a university setting and private radiology clinic. Patient sample Five subjects (three women and two men; mean age, 31.6 years; standard deviation [SD], 12.4). Methods Each subject was examined by a researcher experienced in manual medicine to assess active range of neck movement and the side and symptomatic segmental level of pain. Subjects then underwent a blinded MRI investigation, which included sagittal images through the entire neck and cervical spine and axial images from C2 to T1. Evidence of capsule or periarticular edema and joint space T2 increase was recorded and scored. Additionally, signs of muscle edema, alignment, disc disease, facet arthritic change, and spinal stenosis were recorded. Results Subjects presented with mean current pain of 4.8 (SD, 1.6; visual analog scale, 0–10), worst pain since onset of 7.0 (SD, 0.7), and duration of symptoms of 12.4 hours (SD, 14.1). The plane of active motion most commonly limited was rotation to the painful side, followed by side bending to the painful side and extension. No MRI findings demonstrated clear evidence of synovial effusion or inflammation around the joints of the cervical spine. In some individuals, signs of muscle edema, altered alignment, disc and facet arthrosis, and spinal stenosis were noted, but these did not appear to be related to the side of pain or symptomatic level. Conclusions No evidence of cervical joint inflammation was detected, and more sensitive imaging methods may be required to detect inflammatory changes in or around the cervical joints of subjects with acute benign neck pain. Recruitment of subjects with acute “crick in the neck” pain (<48 hours duration) is difficult but feasible over a long data collection period.

Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: A feasibility study

Magnetic resonance imaging of subjects with acute unilateral neck pain and restricted motion: A feasibility study

What Does Local Tenderness Say About the Origin of Pain? An Investigation of Cervical Zygapophysial Joint Pain

Mechanical pain sensitivity is assessed in every patient with pain, either by palpation or by quantitative pressure algometry. Despite widespread use, no studies have formally addressed the usefulness of this practice for the identification of the source of pain. We tested the hypothesis that assessing mechanical pain sensitivity distinguishes damaged from healthy cervical zygapophysial (facet) joints. Thirty-three patients with chronic unilateral neck pain were studied. Pressure pain thresholds (PPTs) were assessed bilaterally at all cervical zygapophysial joints. The diagnosis of zygapophysial joint pain was made by selective nerve blocks. Primary analysis was the comparison of the PPT between symptomatic and contralateral asymptomatic joints. The secondary end points were as follows: differences in PPT between affected and asymptomatic joints of the same side of patients with zygapophysial joint pain; differences in PPT at the painful side between patients with and without zygapophysial joint pain; and sensitivity and specificity of PPT for 2 different cutoffs (difference in PPT between affected and contralateral side by 1 and 30 kPa, meaning that the test was considered positive if the difference in PPT between painful and contralateral side was negative by at least 1 and 30 kPa, respectively). The PPT of patients was also compared with the PPT of 12 pain-free subjects. Zygapophysial joint pain was present in 14 patients. In these cases, the difference in mean PPT between affected and contralateral side (primary analysis) was -6.2 kPa (95% confidence interval: -19.5 to 7.2, P = 0.34). In addition, the secondary analyses yielded no statistically significant differences. For the cutoff of 1 kPa, sensitivity and specificity of PPT were 67% and 16%, respectively, resulting in a positive likelihood ratio of 0.79 and a diagnostic confidence of 38%. When the cutoff of 30 kPa was considered, the sensitivity decreased to only 13%, whereas the specificity increased to 95%, resulting in a positive likelihood ratio of 2.53 and a diagnostic confidence of 67%. The PPT was significantly lower in patients than in pain-free subjects (P < 0.001). Assessing mechanical pain sensitivity is not diagnostic for cervical zygapophysial joint pain. The finding should stimulate further research into a diagnostic tool that is widely used in the clinical examination of patients with pain.

Cervical nerve injection: computed tomography guidance with intravenous contrast and extraforaminal needle placement. Series of seven consecutive case reports

Background context Image-guided cervical nerve injections are being performed with increasing frequency. Severe complications are being reported. Purpose The purpose of this study is to introduce a technique for cervical nerve injection that may decrease the possibility for severe complications. Study design/setting This is a series of case reports describing the technique and clinical follow-up. Patient sample The sample comprises seven consecutive cases of unilateral neck and arm pain referred for cervical nerve injection. Outcome measures Retrospective evaluation of pain relief before and after the injection and at follow-up is reported as case studies. Methods The technique for computed tomography guided cervical nerve injection is described with case reports of seven consecutive patients. Results The results are case reports of each of the seven patients after unilateral cervical nerve injection. Conclusion A technique for cervical nerve injection is described with the results of the injection. This technique may allow some standardization in the procedure, decrease the learning curve for training physicians, and minimize the potential complications.

Carotidynia—A valid cause of unilateral neck pain

Carotidynia is an unusual cause of unilateral neck pain which may be due to inflammation of the carotid artery wall. Its existence as a distinct clinical entity has been questioned due to inappropriate use of the term and a previous lack of confirmatory tests, including imaging, to support a clinical diagnosis of exclusion. We present a case of carotidynia with ultrasound and MR imaging in a patient who presented with a pericardial effusion. We suggest that carotidynia is a valid diagnostic entity and that imaging may be incorporated into any future diagnostic criteria.

The Immediate Effects of Mobilization Technique on Pain and Range of Motion in Patients Presenting With Unilateral Neck Pain: A Randomized Controlled Trial

Kanlayanaphotporn R, Chiradejnant A, Vachalathiti R. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Objective To determine the immediate effects on both pain and active range of motion (ROM) of the unilateral posteroanterior (PA) mobilization technique on the painful side in mechanical neck pain patients presenting with unilateral symptoms. Design Triple-blind, randomized controlled trial. Setting Outpatient physical therapy, institutional clinic. Participants Patients (N=60), 2 physical therapists, and 1 assessor involved in this study. Interventions The patients were randomly allocated into either preferred or random mobilization group by using an opaque concealed envelope. The first therapist performed the screening, assessing, prescribing the spinal level(s), and the grade of mobilization. The second therapist performed the mobilization treatment according to their allocated group stated in an envelope. The assessor who was blind to the group allocation conducted the measurements of pain and active cervical ROM. Main Outcome Measures Pain intensity, active cervical ROM, and global perceived effect were measured at baseline and 5 minutes posttreatment. Results After mobilization, there were no apparent differences in pain and active cervical ROM between groups. However, within-group changes showed significant decreases in neck pain at rest and pain on most painful movement ( P<0.001) with a significant increase in active cervical ROM after mobilization on most painful movement ( P=0.002). Conclusions The results of this study did not provide support for the preference of the unilateral PA mobilization on the painful side to the random mobilization.

Reliability of clinical tests to evaluate nerve function and mechanosensitivity of the upper limb peripheral nervous system

BackgroundClinical tests to assess peripheral nerve disorders can be classified into two categories: tests for afferent/efferent nerve function such as nerve conduction (bedside neurological examination) and tests for increased mechanosensitivity (e.g. upper limb neurodynamic tests (ULNTs) and nerve palpation). Reliability reports of nerve palpation and the interpretation of neurodynamic tests are scarce. This study therefore investigated the intertester reliability of nerve palpation and ULNTs. ULNTs were interpreted based on symptom reproduction and structural differentiation. To put the reliability of these tests in perspective, a comparison with the reliability of clinical tests for nerve function was made.MethodsTwo experienced clinicians examined 31 patients with unilateral arm and/or neck pain. The examination included clinical tests for nerve function (sensory testing, reflexes and manual muscle testing (MMT)) and mechanosensitivity (ULNTs and palpation of the median, radial and ulnar nerve). Kappa statistics were calculated to evaluate intertester reliability. A meta-analysis determined an overall kappa for the domains with multiple kappa values (MMT, ULNT, palpation). We then compared the difference in reliability between the tests of mechanosensitivity and nerve function using a one-sample t-test.ResultsWe observed moderate to substantial reliability for the tests for afferent/efferent nerve function (sensory testing: kappa = 0.53; MMT: kappa = 0.68; no kappa was calculated for reflexes due to a lack of variation). Tests to investigate mechanosensitivity demonstrated moderate reliability (ULNT: kappa = 0.45; palpation: kappa = 0.59). When compared statistically, there was no difference in reliability for tests for nerve function and mechanosensitivity (p = 0.06).ConclusionThis study demonstrates that clinical tests which evaluate increased nerve mechanosensitivity and afferent/efferent nerve function have comparable moderate to substantial reliability. To further investigate the clinometric properties of these tests, more studies are needed to evaluate their validity.

Controversies in the management of tongue base cancer

Tongue base cancer is one of the most lethal head and neck cancers. There is considerable controversy in the management of this disease with wide variation of opinion within the literature. We discuss the presentation, diagnostic and therapeutic strategies which exist in the literature. Articles were reviewed from 1970 to 2007 within the Medline, Pubmed and Cochrane libraries. Smokers with a history of persistent unilateral neck pain, even in the absence of clinical signs warrant MRI neck imaging. Tongue base cancer organ preservation therapeutic strategies, radiation and concomitant platinum based chemotherapy, currently optimise oncologic and quality of life outcomes.

Diagnose und Verlauf von Carotisdissektionen*

33 patients with angiographically confirmed dissection of the internal carotid artery (ICA) were followed prospectively. Cardinal symptoms were: 1) focal disturbances of the cerebral circulation (n = 28); 2) unilateral headache or neck pain (n = 20); 3) incomplete Horner's syndrome (n = 9). Neurological deficits without pain or sympathetic nerve damage developed in 11 patients. All patients had abnormal Doppler ultrasound findings over the ICA; in 22 there were markedly reduced flow velocities and retrograde flow components ("to- and- fro" phenomenon), typical of carotid artery dissection. During a mean observation time of 6.9 +/- 5.7 months serial Doppler ultrasound and angiographic examinations demonstrated recanalization in 73% after an average of 56 days. Angiographically different types (long segments in 13; pseudo-occlusions in 7; pseudoaneurysms in 5; and distal stenoses in 6; others in 2) are interpreted as expressions of different stages in the development of dissection up to complete recanalization.

Relative Therapeutic Efficacy of Some Vertebral Mobilization Techniques in the Management of Unilateral Cervical Spondylosis: A Comparative Study

[Purpose] This study compared the relative efficacy of Posterior-Anterior Unilateral Pressure (PAUP), Anterior-Posterior Unilateral Pressure (APUP), Cervical Oscillatory Rotation (COR) and Transverse Oscillatory Pressure (TOP) techniques of manual therapy in the management of unilateral cervical spondylosis. [Subjects and Methods] Twenty-four male subjects in each of four groups (96 patients; age range 40-50 years, mean 44 ± 5.3 years) received treatment 3 times per week for four weeks. Mean treatment time, pain recovery pattern (pain-free, residual pain, fair improvement, no change or worse) and relapse after 3 months were outcome measures. [Results] Significantly (P<0.001) less time was spent applying APUP (130 min) and PAUP (156 min) than COR (192 min) and TOP (219 min) with significantly (P<0.001) more pain-free patients in APUP (63%) and PAUP (46%) groups than in COR (17%) and TOP (25%) groups. Relapse rates after 3 months were 8% (TOP) and 12% (COR) and these treatments had no effect on symptoms of 4% and 8% of patients, respectively. [Conclusion] APUP and PAUP achieve faster pain relief in more patients with unilateral cervical spondylosis than rotation and transverse pressure. Unilateral pressures should be preferred techniques of manual therapy for patients with unilateral neck pain and APUP promise a better outcome.

Scintigraphy in Diagnosing Neck Pain

AbstractIn this prospective study with independent clinical review, reported results of scintigraphy were compared to clinical examination findings and patient symptoms to determine if there was a correlation between a high level of uptake of radioactive tracer and the source of intractable, axial, unilateral neck pain in 32 consecutive patients, 19 males and 13 females, whose average age was 63 years (range 34-80). The findings were gathered over a 7 year period, giving up to 7 years follow-up. The purpose was to ascertain whether scintigraphy is useful in the diagnosis and treatment of intractable, unilateral, axial neck pain.Adults presenting with intractable unilateral axial neck pain, persistent for an average of 15 months (3-86) were offered scintigraphy. The patient’s scans were reviewed to determine if there was a correlation between clinical findings and scintigraphy. If there was, patients were admitted to the study and went on to have specific injections and manipulation to the facet joints ide...

Neck flexor muscle fatigue is side specific in patients with unilateral neck pain

Despite the evidence of greater fatigability of the cervical flexor muscles in neck pain patients, the effect of unilaterality of neck pain on muscle fatigue has not been investigated. This study compared myoelectric manifestations of sternocleidomastoid (SCM) and anterior scalene (AS) muscle fatigue between the painful and non-painful sides in patients with chronic unilateral neck pain. Myoelectric signals were recorded from the sternal head of SCM and the AS muscles bilaterally during sub-maximal isometric cervical flexion contractions at 25% and 50% of the maximum voluntary contraction (MVC). The time course of the mean power frequency, average rectified value and conduction velocity of the electromyographic signals were calculated to quantify myoelectric manifestations of muscle fatigue. Results revealed greater estimates of the initial value and slope of the mean frequency for both the SCM and AS muscles on the side of the patient’s neck pain at 25% and 50% of MVC. These results indicate greater myoelectric manifestations of muscle fatigue of the superficial cervical flexor muscles ipsilateral to the side of pain. This suggests a specificity of the effect of pain on muscle function and hence the need for specificity of therapeutic exercise in the management of neck pain patients.

Pain and muscular responses to a neural tissue provocation test in the upper limb

Pain and muscular responses to a Neural Tissue Provocation Test with bias to median nerve were examined in 20 asymptomatic subjects. The test was performed on both arms with the cervical spine in a neutral position and in contralateral sideflexion as a sensitizing manoeuvre. The angle of elbow extension at the time of onset of pain and muscle activity in trapezius, biceps and triceps muscles was measured using an electrogoniometer. Muscle activity was recorded by surface electromyography. Results indicate that pain responses and muscle activity of trapezius are present in the majority of normal subjects. The onset of pain was highly reliable and compared favourably with detection of muscle activity onset. There was no significant difference of the angle of the elbow with the onset of pain between arms. Hence in patients with unilateral neck or upper limb pain a difference between sides might be indicative of a possible neural tissue involvement.Pain and muscular responses were influenced by the position of the cervical spine. This finding suggests that cervical contralateral sideflexion has a sensitizing effect on neural tissues. There was an association between the onset of pain and onset of trapezius muscle activity in all painful trials. However, muscle activity was also present in subjects with no pain.

The Short-Term Effect of Manipulation and Mobilization on Pain and Range of Motion in Patients With Mechanical Neck Pain

Objective: To determine the short term effects of cervical manipulation and mobilization in patients with cervical pain and limited motion. Design: Seventy-six consecutive outpatients were studied in one-group-repeated design without long-term follow-up.Setting: An university sports medicine clinic in Ankara, TurkeyPatients: All patients had unilateral neck pain without neurological deficit. Ninety-six consecutive patients ( forty-two men and fifty-four women; Group I: 76 and Group II: 20 patients), aged between 20 and 55 years, were selected on the basis of clinical suspicion for mechanical cervical problems between January 1994 and December 1998. All patients complained of cervical pain and/or stiffness on one side for a period of one week to 4 months. All patients completed the study.Interventions: Group I (study group) received mobilization including general manual traction, gliding and rotational mobilization and Group II (control group) infrared lights, TENS and exercise three times a week for a period of 3 weeks. Group I also received a single cervical manipulation composed of gentle passive forceful movement (Grade C) as described by Cyriax.Main Outcome Measures: Pain and active range of motion were assessed before, immediately after and the day following treatment. Cervical range of motion was evaluated with a Cyriax Neck Form and pain was measured by using a visual analogue scale.Results: The results showed mobilization and manipulation techniques increased active range of motion and decreased pain immediately after treatment (p<0.05). Medication usage of all patients except four decreased after treatment.Conclusions: This study showed the effectiveness of manipulation and mobilization techniques in the short-term on seventy-six patients with mechanical neck pain. Further controlled studies are required to determine any long-term benefits of manipulation and mobilization for mechanical neck pain.