ASSESSMENT OF NECK PAIN AND ITS ASSOCIATED DISORDERS: RESULTS OF THE BONE AND JOINT DECADE 2000–2010 TASK FORCE ON NECK PAIN AND ITS ASSOCIATED DISORDERS
 
   

Assessment of Neck Pain and Its Associated Disorders:

Results of the Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
    Frankp@chiro.org
 
   

FROM:   J Manipulative Physiol Ther. 2009 (Feb);   32 (2):   S117–S140 ~ FULL TEXT
Republished from:   Spine (Phila Pa 1976). 2008 (Feb 15);   33 (4 Suppl):   S101–S122


Margareta Nordin, PT, Dr Med Sc, Eugene J. Carragee, MD, FACS,
Sheilah Hogg-Johnson, PhD, Shira Schecter Weiner, PT, PhD (Candidate),
Eric L. Hurwitz, DC, PhD, Paul M. Peloso, MD, MSc, FRCP(C),
Jaime Guzman, MD, MSc, FRCP(C), Gabrielle van der Velde, DCs,
Linda J. Carroll, PhD, Lena W. Holm, Dr Med Sc, Pierre Côté, DC, PhD, J.
David Cassidy, PhD, Dr Med Scm, Scott Haldeman, DC, MD, PhD

Department of Orthopaedics and Program of Ergonomics and Biomechanics,
School of Medicine and Graduate School of Arts and Science,
New York University, NY, USA.
margareta.nordin@nyu.edu


STUDY DESIGN:   Best evidence synthesis.

OBJECTIVE:   To critically appraise and synthesize the literature on assessment of neck pain.

SUMMARY OF BACKGROUND DATA:   The published literature on assessment of neck pain is large and of variable quality. There have been no prior systematic reviews of this literature.

METHODS:   The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders conducted a critical review of the literature (published 1980-2006) on assessment tools and screening protocols for traumatic and nontraumatic neck pain.

RESULTS:   We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.

CONCLUSION:   The scientific evidence supports screening protocols in emergency care for low-risk patients; and CT-scans for high-risk patients with blunt trauma to the neck. In nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests is lacking. There is support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research. evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for WAD. Recovery of WAD seems to be multifactorial.



From the Full-Text Article:

Introduction

From the conceptual model presented in Guzman et al, [1] people with neck pain may or may not seek care for their symptoms. For those who do, once they enter the clinical setting, the diagnostic process begins.

Diagnostics is the process of identifying a medical condition or disease by its signs and symptoms from the results of a clinical examination and other evaluative procedures. The conclusion reached through this process is called a diagnosis. Diagnostics may be used to either “rule in” or, to “rule out” a condition, disease, or disorder. The term “diagnostic criteria” designates the combination of findings which allows the clinician to ascertain the diagnosis of the respective disease.

Typically, someone with abnormal symptoms will consult a physician, who will then obtain a history of the patient's illness and examine the individual for signs of disease. The clinician will formulate a hypothesis of likely diagnoses and in many cases will obtain further testing to confirm or clarify the diagnosis, before suggesting definitive treatment.

In modern Western medicine the diagnoses of illness, along with the diagnostic accuracy of individual or combined diagnostic tests, serves as the basis for decisions on treatment strategies, referrals, disability assessments, reimbursement, and more.

This article presents the main results of a systematic review looking at the evidence regarding the validity and utility of diagnostic tests and self-reported disability assessment in people with neck pain. It is hoped that our best evidence synthesis approach will serve to inform clinicians on how best to confirm or refute a diagnosis or confirm a diagnosis. (Note: The literature search and critical review strategy are outlined in detail in Carroll et al. [2])



Discussion

      Emergency Screening for Serious Neck Injuries in Patients With Blunt Trauma to the Neck

There is strong evidence from several high quality phase III studies to suggest that practitioners can reliably employ either the Canadian C-spine rules (CCR) 15 or the Nexus low-risk criteria (NLC) 20 to rule out the need for further imaging in adult patients at low risk of neck pain injury seeking emergency care ( Fig 1 and Table 6 ). [13-22]

There is strong evidence to suggest that use of routine cervical spine radiographs alone, (compared to CT scans) may miss important injuries in the evaluation of patients with traumatic high-risk neck injuries in emergency situations, and that CT scan should be used instead. [10 , 24-30] Coupled with the fact that there is important variability in reading the plain radiographs and that there is good evidence to suggest that the CT scan has a superior performance, routine radiographs alone may be superseded by CT in the setting of acute neck trauma in high-risk patients. Where CT scan facilities are not available to patients with high-risk injuries and radiographs are inconclusive, patients may need to be stabilized, and transported to facilities with other imaging alternatives. Enthusiasm for CT imaging in cervical trauma must be tempered by the economic burden if universally applied and the much higher radiation exposure to sensitive tissues, especially in children and younger adults. [124, 125]

Our evidence review suggests that there is lack of guidelines for children and neck trauma injuries; developing and testing such guidelines should be a priority for the clinical research community.

      Clinical Assessment of Nonemergency Neck Patients

There is insufficient available evidence to confirm the utility of conventional “Red Flag Symptom” for triaging nonacute neck patients, although their use has been strongly encouraged [41] ( Table 6 ). Although it is sensible that the same types of presentation (or predisposing risk) of serious structural disease that occurs in the lumbar spine 39 may also occur in the cervical spine, the cervical spine area has special anatomic considerations and risks (e.g., the presence of the spinal cord, specific rheumatoid destructive processes, specific adjacent vascular and visceral diseases). These idiosyncratic processes demands objective evidence and further studies be performed to define those subgroups of neck pain patients at higher risk as a result of these serious structural diseases.

We suggest a new classification for Neck Pain expressed as grade I–IV encompassing all neck pain building on the Québec Task Force Classification [7] as a diagnostic classification for the conditions including neck pain with and without trauma not leading to serious injury or diseases. WAD and other neck pain do not differ once serious neck conditions have been ruled out. The classification is based on 5 axes including the source of subjects, the setting and sampling of subjects or patients and the severity, duration, and pattern of neck pain. [1] The new proposed classification for neck pain and its associated disorders has not been validated.

Remarkably, there is little information on the validity or utility of the self-reported history in evaluating neck pain disorders. There is some information that self-reported questionnaires regarding past medical care may not have a high accuracy. [103] Similarly, data from the orthopedic trauma literature (not specifically reviewed for the Neck Pain Task Force) suggests the history received in specialty spine clinics in subjects reporting continued axial pain after MVA may systematically underestimate previous low back and neck pain problems and comorbidities associated with poor recovery. [117]

The current literature indicates that the clinical routine physical examination is more effective in ruling out cervical radiculopathy than confirming its presence. An exception is the manual provocation test for nerve root compromise, which seems to have a high sensitivity and high PPV.

As far as the physical examination of patients seeking care for neck pain with associated disorders, there is some evidence that some features of inspection, range of motion, strength, palpation, and provocation tests can be useful. Inspection of the neck patient for abnormal signs (for example, muscle wasting, swelling, redness, scars, and others) has low to moderate interexaminer reliability. Range of motion is moderately reliable, and it does not seem to matter whether it is assessed by the clinician (assessing active, or passive range of motion with or without a device), or whether it is self-described by the patient.

In addition, the available evidence suggests that subjects with neck pain identify discomfort with palpation for trigger points around the neck had moderate to high predictive value for neck pain with and without radiculopathy. Manual provocation tests designed to elicit nerve root compression in the cervical spine also have high positive predictive value (i.e., ruling in radiculopathy). Beyond the physical examination, there is no good evidence from this systematic review that laboratory studies provide any unique value, or that surface, dermatomal, or quantitative sensory electrophysiological studies provide useful ancillary data. Needle EMG examination, although not specifically studied for cervical radiculopathy, is considered the gold standard test for denervation from any cause.

Several studies examined the role of imaging. There does not seem to be good evidence supporting the utility of plain radiographs in patients seeking nonacute care for neck pain who do not have major structural disease. No CT scan study was accepted for predictive values in the nonacute patient with neck pain with and with out radiculopathy. Despite the many potential advantages of MRI in detecting major structural disease (e.g., neoplasm, infection, etc.), current multiple scientifically admissible studies do not suggest that it has any unique role, independent of the history and clinical examination in detecting the cause of neck pain. Combined with symptoms of radicular complaints, specific findings on examination, and possibly needle EMG findings, the MRI may aid clinicians in determining the site and level of neurologic compression.

Other specialized investigative techniques, such as anesthetic facet joint injections and provocative discography, purported to “definitively” identify primary and specific lesions causing serious neck pain illness, do not seem to be supportable based on the current evidence and cannot be recommended as a routine part of clinical practice.

Patient self-assessment questionnaires seem to deserve greater use in routine clinical practice and research. The instruments cited have demonstrated acceptable reliability; many are suitable to characterize patients clinically, have good content validity and are responsive to changes of the patients self reported status. It is unclear from the current systematic review if specific results from these questionnaires are useful in predicting long-term outcome related to pain, disability, and employment. [118-120]


      Some Limitations of Our Research

There are limitations of this chapter that merit some discussion. Like all best evidence syntheses, this chapter is limited by both the quantity and the quality of the available evidence. We were surprised at the limited number of studies in several areas, for example, in special populations (children and elderly), electro diagnostics, functional testing, and the use of imaging in diagnosing patient with neck pain in nonemergency situation. We were also surprised at the limited quality of studies, notably, we found only 1 phase IV study addressing the health care consequences addressing mobilization of the neck, [6] and few phase III studies (including gold standard for assessment) in the nonemergency patient populations.

We realize that some readers, who are unfamiliar with the best evidence synthesis approach to summarizing the literature, may not appreciate its value. However, we feel that limiting our conclusions to studies that are of high methodologic quality is a notable strength. An uncritical mixing of studies of lower and higher quality scientific merit would yield potentially confusing and misleading results.

      Directions for Future Research

  • There is an urgent need for studies of pediatric populations and neck trauma. It is important to understand if modifications of the CCR or the NLC apply to the pediatric population.

  • There is a need to test several, potentially promising techniques or commonly used clinical tests in proper designs that have shown promise in phase I and II studies, for example, test of nonorganic signs and functional tests.

  • There is an immediate and strong need to test almost all commonly used clinical examination tests against gold standards, for predictive values and for utility in patients with non serious neck pain and associated disorders. Only provocation tests for cervical radiculopathy were well tested against gold standards [8, 55, 64, 66] and manipulation was tested for utility. [6]



      Evidence Statements

Clinical Emergency Screening for Serious Neck Injury in Patients With Blunt Trauma to the Neck

  • There is strong consistent evidence from 11 studies (phase II and III) of large cohorts that using screening protocols for alert low-risk patients with blunt trauma to the neck will have high predictive values for detecting a cervical spine fracture. The CCR and the NLC have tested more than 40,000 patients. These protocols were tested against a 3-view radiograph as the gold standard, and appear to have an extremely low risk of missing a serious injury in this group. [13-17, 19-23, 31, 32]

  • There is consistent evidence that CT-scan (7 studies phase II and III) is more sensitive for finding significant cervical spine injury than plain 3-view radiograph in patients (adult and elderly) with cervical trauma for high risk and/or multi-injured blunt trauma neck patients seeking care in an emergency room. [10, 24, 25, 27-30]

  • There is evidence (1 phase I and 1 phase II study) suggesting indicators for screening for serious injury in children seeking care for neck trauma. Suggested indicators are neck pain, altered mental state, abnormal peripheral neurologic examination (sensation, reflexes, strength). [33, 34]

  • There is evidence against (1 phase I and 1 phase III study) the use of flexion/extension (F/E) radiographs or 5-view radiograph of the cervical spine in adults and children seeking emergency care for acute blunt trauma to the neck. F/E radiograph or 5-views radiograph did not have higher accuracy than standard 3-view radiograph in these studies. [22, 35]

  • There is limited evidence (1 phase III study) that specialty training for clinicians in the ability to interpret radiograph films in emergency situations for patients with blunt trauma to the neck improves the reliability of the image interpretation and thereby possibly increasing the diagnostic accuracy. [36]

  • There is limited evidence (1 phase I study) of the predictive value using a specific screening protocol by EMT workers for immobilizing and transporting patients with suspected neck trauma to the emergency room. [37]

  • There is no evidence (no study) to support the routine use of MRI as a screening tool after acute neck blunt trauma in an emergency setting.



Clinical Assessment in Non-Emergency Care of Patients With Neck Pain (With and Without Arm Pain and/or Headache)

      Clinical Physical Examination

  • There is consistent evidence that the clinical physical examination is generally more predictive at excluding (“ruling out”) a structural lesion or neurologic compression than at diagnosing (“ruling in”) root compression and radiculopathy. [8, 55, 64, 66]

  • There is consistent evidence that measuring normal cervical range of motion (14 phase I–III studies) is equally reliable whether measured by visual estimation or external device. Patients' estimates of reduced range of motion of the neck are less accurate. [9, 44-52, 54, 55, 57, 58] There is evidence from 2 studies (phase I) that chronic WAD patients and subjects with neck pain and myalgia have less mobility in the cervical spine compared with controls. [54, 60] There is evidence from 1 study that patients reporting acute WAD problems have decreased volitional range of motion of the neck compared to asymptomatic controls. [56]

  • There is limited evidence (1 phase I study) that patients with chronic neck pain, on average, have slightly lower neck muscle strength compared with controls. [50]

  • There is evidence (2 phase I studies) that cervical flexor endurance or arm flexor endurance can discriminate between subjects reporting chronic WAD II problems or subjects with neck pain and myalgia compared to controls. [60, 61]

  • There is consistent evidence that trigger-point palpation by a clinician (3 phase I studies) or “patient self-palpation” compared with physician palpation is reliable. [58, 63, 64] There is limited evidence (1 phase II study) that patients with neck pain and those with suspected radiculopathy have similar trigger point distributions. [65]

  • There is consistent evidence in patients with radiculopathy (2 phase II studies) that sensory examinations, which demonstrate increased sensitivity to light touch and pin prick, are more reproducible than examinations demonstrating decreased sensation. [44, 55] There is limited evidence (1 phase I study) that when subjects fail to identify a sensory change on self-assessment significant nerve root compression is highly unlikely to be found at physician examination. [58]

  • There is limited evidence (1 phase I study) against the use of low-amplitude manipulation and endplay assessment of the cervical spine in patients with neck pain. One randomized phase IV trial showed that this assessment did not improve the primary outcome of same day pain level and stiffness relief observed in neck pain patients. These findings need to be replicated. [6]

  • There is consistent evidence (3 phase III studies and 1 systematic review) to support the use of radicular pain provocation tests for neck patients to detect probable nerve root compression findings. The most predictive test included contralateral neck rotation and extension of the arm and the fingers of the affected side. [8, 55, 64, 66]

  • There is evidence against the use of routine blood tests to distinguish patients with acute whiplash exposure or chronic neck pain complaints from those subjects without exposure to whiplash or chronic neck troubles (2 phase I studies). [63, 69] Routine blood tests could not distinguish patients from nonpatients at late stage of WAD or chronic neck pain.

  • There is limited evidence (1 phase II study) that patients with chronic neck pain may perform less well on certain functional test. [67]

  • There is consistent evidence that nonorganic sign tests had high inter-rater variability among clinicians testing patients with chronic neck pain. [55, 68]

  • There is evidence against the use of electrodiagnostic testing in patients with neck pain without suspected radiculopathy. Two studies (phase I and II) found that surface EMG activity of the upper trapezius muscle did not distinguish between subjects with and without neck pain. [71, 72]

  • There is no evidence that the degree of cervical lordosis or kyphosis can accurately distinguish “cervical muscle spasm” or subjects with whiplash exposure from those with no exposure to whiplash. One study (phase I) found that there is no difference in cervical lordosis or kyphosis in patients with subacute WAD compared with controls as documented by radiograph. [75]

  • There is no evidence (no scientifically admissible studies) to support the use of surface electromyelography, dermatomal somatosensory-evoked responses or quantitative sensory testing in the diagnosis of radiculopathy.

  • There is limited evidence (1 phase II study) that the assessment of root compression or canal stenosis of the cervical spine by CT scan has fair to moderate reliability. [77]

  • There is no evidence that pain reproduction on provocative disc injection identifies the injected disc as the cause of primary serious neck pain problems. There is weak evidence against provocative discography of the cervical spine in patients with neck pain. There is evidence (1 phase II study) that pain response to provocative discography cannot accurately distinguish between subjects with and without neck pain. [78] There is no evidence that provocative cervical discography has clear utility in treating patients with neck pain (i.e., improves outcomes). [78, 79]

  • There is consistent evidence from (4 phase I studies) that the identification of common degenerative changes in the cervical spine, identified by MRI is at best fair to moderately reproducible. [77, 82, 84, 85]

  • There is evidence against the use of a digitizer to enhance MRI readings or enhanced MRI (2 phase II studies) to improve reliability in reading MRIs for the cervical spine findings. [83, 87]

  • There is evidence (2 phase II studies) that cervical MRI findings of a hard disc or extrusion of disc material through the cervical posterior longitudinal ligament are often not in agreement with the surgeon-reported findings at surgery. [88, 89]

  • There is no evidence that common degenerative changes on cervical MRI are strongly correlated with neck pain symptoms. There is evidence (4 phase I and II studies) that MRI findings of the cervical spine of common degenerative changes are highly prevalent in asymptomatic subjects. Abnormal MRI findings of the cervical spine also found to increase with age. [82, 90-92]

  • There is evidence (1 phase I study) that frequent exposure to extremely high g-forces in senior fighter pilots compared to controls is associated with increased cervical disc degeneration. [93]

  • There is no evidence that standard sequence MRI accurately detect specific trauma-related findings in the subaxial cervical spine in the absence of fracture, dislocation or major ligamentous disruption. There is evidence (1 phase II study) that patients with acute WAD do not have soft tissue lesions of the cervical spine demonstrated by MRI. [94]

  • The validity of high-intensity signals MRI findings in the upper cervical spine ligaments as representing acute whiplash injury has not been demonstrated. There is evidence (3 phase I studies) that identifying signal changes in the ligaments of the upper cervical spine in late stage of WAD by special sequence MRI had slight to moderate reliability. [84, 85, 86] The utility of this finding in diagnosing bona fide and clinically relevant ligamentous injury and directing effective treatment has not been demonstrated in WAD patients (grade I–III).

  • There is no evidence that common degenerative changes on cervical MRI are associated with pain in patients with supposed cervicogenic headache. One phase I study found similar MRI findings in cervicogenic headache patients and asymptomatic controls. [95]

  • There is no evidence supporting the validity of diagnostic facet joint or medial branch blocks as diagnosing cervical facet joint pain as the primary cause of serious neck pain illness. There is evidence against (4 phase II studies) the use of diagnostic facet joint or medial branch injections of the cervical spine; these studies show poor reliability. There is no evidence that the use of diagnostic facet injections improves treatment outcomes (utility) in patients with chronic neck pain. [ 97-100]



      Self-assessment by Questionnaires

  • There is consistent evidence that patient self-assessment questionnaires may have utility in routine clinical practice and research by characterizing patients' clinical presentation, subjective functional impact of neck pain and course over time.

  • There is no evidence (no studies) that a self-assessment questionnaire alone can accurately diagnose a structural cause of illness in patients with neck pain. However, the questionnaires cited in this systematic literature review can provide useful information regarding patient self-assessment for pain, function, and perceived disability and psychosocial status.

  • Overall there was evidence for moderate to strong performance of all the questionnaires cited for reliability, validity, and responsiveness to change in this systematic literature review. Not all parameters of performance for an instrument cited have been measured for all questionnaires in the scientifically admissible studies. [47, 62, 101-103, 105-109, 111, 114-116]

  • There is evidence (14 studies) that neck specific questionnaires are more responsive to changes in the neck pain and to differences among various groups of patients with neck pain than generic pain questionnaires. [47, 62, 101-109, 111, 114-116]

  • There is evidence that generic questionnaires may be more useful than neck specific questionnaires for comparing individuals with neck pain with other disease groups (see Table 5 ). [47, 51, 55, 104, 108-110]

  • There is evidence against (1 study) in patients with neck pain to use self-assessment questionnaires to monitor health care utilization i.e., the study showed that patients had poor recollection of healthcare utilization. [103]



      Research Recommendations

As the preceding evidence statements suggest, there are large areas in the diagnostic testing of neck pain associated disorders that are poorly validated, even at the most elementary levels. Few clinical entities related to neck pain have been systematically investigated except the emergency screening for blunt trauma to the neck. Despite the lack of adequate supporting evidence apparent in our comprehensive review, in clinical practice “diagnoses of convenience” are often made. Diagnoses such as “cervical sprain,” “minor facet subluxation,” “primary discogenic pain,” “internal disc derangement,” “postural neck pain,” “primary zygapophysial pain,” and others have been in common usage for decades, often without confirmation of the entity itself or any means of diagnosis according to accepted scientific methods. Tests claiming to make these diagnoses need to be rigorously tested and clear strategies to do so have been well described. [5, 121, 122, 123]

Investigators interested in designing appropriate studies are strongly advised to consider established guidelines to ensure study validity (e.g., appropriate subject composition, avoidance of work-up bias, avoidance of review bias, testing for reproducibility, and others). Equally important is the need to clearly establish gold standard comparisons that exist outside the test being evaluated. [117, 122] As Greenhalgh [122] points out one must be certain “that the test being validated is not being used to define the gold standard.” This is very common error in spinal diagnostic research.

Most importantly, it must be clear where the burden of proof lies in the study of diagnostic methods. Diagnostic tests must be assumed clinically uninterpretable until their validity and limitations are established. More often in our review, we have seen tests advocated for popular use on the reverse premise: the tests must be assumed valid until someone can show they are worthless (e.g., provocative discography). Tragically, the spinal literature of the last century is littered with “definitive diagnoses” of pain syndromes, based on a novel test only to be abandoned as invalid only after many years of inappropriate use (e.g., “definitive axial pain diagnoses” on the basis of radiographs showing bone spurs or minor alignment changes, bone scans showing increased uptake, MRI showing disc signal loss, facet injections giving temporary pain relief, etc.).

Clinicians should know what a test's accuracy and limitations are before using it, clinician–investigators need to appreciate that it is very difficult and sometimes impossible to scientifically disprove an ill-defined theory whether it be “intelligent design,” “cervical sprain,” “joint instability,” or “internal disc derangement.”



      Specific Areas of Inquiry

  • There is a need to establish screening criteria for infants, children, and adolescents seeking care in an emergency room for blunt trauma a to the neck (phase III and IV studies).

  • There is a lack of consistency among emergency physicians to interpret radiograph and other imaging in emergency situations for patients with blunt trauma to the neck. Better-designed studies are needed for the most efficacious training of imaging interpretation of these patients' films.

  • There is a need to validate and establish the relative utility and cost-effectiveness of screening patients seeking treatment for nonemergency/nontraumatic neck pain for serious structural disease (“Neck Pain Red Flags”) (phase I–IV studies).

  • There is a need to confirm the validity and utility (phases III–IV study) of the clinical musculoskeletal neck examination in patients with neck pain without radiculopathy.

  • There is a need to further establish reliability (phase II) and to establish validity and utility of muscle strength and endurance testing of the neck (phase III and IV studies).

  • There is a need to replicate the evidence against the utility of using manipulation of the neck to direct specific treatment in patients with neck pain with or with out radiculopathy (phase IV study).

  • There is a need to establish reliability, validity, and utility of functional capacity testing in patients with neck pain with and without radiculopathy (phase I–IV studies).

  • There is a need to establish validity and utility of the nonorganic-signs test in patients with chronic neck pain (phase III and IV studies).

  • There is a need to evaluate dermatomal somatosensory-evoked responses or quantitative testing in the diagnosis of radiculopathy (phase I–IV studies).

  • There is a need for more robust studies to validate the utility of CT-scan in the assessment of root compression in patients with neck pain and radiculopathy (phase II–IV studies).

  • There is a need to demonstrate validity and utility of MRI for patients with acute and chronic WAD II in well-designed studies (phase III–IV studies).

  • There is a need to examine the gold standard criteria for many basic neck pain diagnoses. Of the many unvalidated tests and diagnoses these common purported diagnoses may deserve early attention: “cervical strain,” “spinal malalignment,” “cervical instability,” “zygapophysial pain,” “cervicogenic headache,” “internal disc derangement,” “discogenic neck pain,” or “minor disc protrusion” as a cause of neck pain without radiculopathy.

  • There is a need to identify clinical subgroups of patients (with neck pain and radicular pain) who are most likely to respond to standard surgical treatment (phase III and IV studies).

  • There is a need to measure all performance parameters simultaneously (reliability, validity, responsiveness to change, and easy of administration) in the neck specific self-assessment questionnaires.

  • There is a need to identify or develop questionnaires useful to describe healthcare utilization in patients with neck pain with and without radiculopathy and/or headache.




Key Points

The scientific evidence strongly supports the use of:

  • Screening protocols in emergency care in low-risk patient with blunt trauma to the neck.

  • CT-scanning in emergency care for high-risk patients with blunt trauma to the neck.


In patients seeking care for nonemergency neck pain,
the scientific evidence supports the use of:

  • Manual provocation tests in patients with neck pain and suspected radiculopathy.

  • The combination of history, physical examination, modern imaging techniques,
    and needle EMG to diagnose the cause and site of cervical radiculopathy.

  • Self-reported patient assessment to evaluate perceived pain, function, disability,
    and psychosocial status.


In patients seeking care for nonemergency neck pain,
there is no evidence to support the diagnostic validity
or utility of using:

  • Provocative discography.

  • Anesthetic facet or medial branch blocks.

  • Surface electromyography, dermatomal somatosensory-evoked responses or
    quantitative sensory testing in the diagnosis of radiculopathy.



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