7 Colo. Code Regs. § 1101-3-17-08-4
Introduction. Initial and follow-up diagnostic evaluation of neck pain may include a clinical history, physical examination, laboratory studies, imaging studies, and electrodiagnostic studies. Please see specific sections for diagnostic injections.
Recommendations.
Initial Diagnostic Studies Requirements.
Recommendation 11. A detailed history of pain onset, past medical history, and a detailed neurologic examination are required at the initial neck pain evaluation (tables 1, 2).
Recommendation 12. Medical causation must establish that neck pain is a result of a specific injury, an aggravation of an underlying condition, or a previously asymptomatic condition made symptomatic by a work-related exposure (table 3).
Recommendation 13. Initial functional assessment is strongly recommended. See the Appendix Functional Screens.
Recommendation 14. A psychological screen is encouraged as a routine part of clinical care and is required as soon as any of the following barriers to functional recovery are identified (Appendix Psychological Screens):
* limited patient engagement in recovery,
* activity avoidance or catastrophization due to pain,
* avoidance of essential recovery activities,
* inappropriate expression of a sense of injustice,
* exaggeration of symptoms/situation,
* low expectations of recovery,
* ineffective coping skills, or
* loss of vocational connection.
Individuals with barriers to functional recovery may benefit from an interdisciplinary approach to care (table 4).
Recommendation 15. Imaging studies are recommended if the patient is 55 years or older, if there is a history of significant trauma, if there is persistent or unexplained pain after 6 weeks, or if there is concern for any of the following:
* fracture,
* instability,
* occult cancer,
* weakness,
* pain worse at rest,
* epidural abscess, or
* myelopathy.
Documentation shall include the specific findings under investigation and how the imaging test will influence treatment.
Recommendation 16. Dynamic fluoroscopy is permitted in the initial or follow-up evaluation of cervical spine trauma and in select cases for comprehensive evaluation of neck and radicular pain.
Recommendation 17. When clinically indicated, early laboratory studies may be ordered to evaluate for systemic illness, infection, neoplasia, underlying rheumatologic, or connective tissue disorder.
Follow-Up Diagnostic Studies Requirements.
Recommendation 18. A formal psychological or psychosocial evaluation is required for patients not making expected progress within 6 weeks of injury and whose subjective symptoms do not correlate with objective signs and tests. See the Behavioral and Psychological Interventions section.
Recommendation 19. Magnetic resonance imaging (MRI) is indicated when there is concern for myelopathy, masses, infection, metastatic disease, or cord contusion. MRI is recommended for patients who have responded poorly to initial care and there is clinical suspicion for disc herniation or nerve root compression. Contrast MRI can be used when there is a history of cervical surgery or if there is possible infection, malignancy, or tumor (table 5).
Recommendation 20. Computed tomography (CT) scan is permitted to better visualize bone and to further evaluate masses and suspected fractures not clearly identified on radiographic evaluation.
Recommendation 21. Myelography is a diagnostic option when:
* CT or MRI are contraindicated or not available, and
* when other tests have proven non-diagnostic in the surgical candidate.
Recommendation 22. Radioisotope bone scanning is permitted when there is clinical suspicion for metastatic or primary bone tumors, occult or stress fractures, osteomyelitis, infection, or other inflammatory lesions.
Recommendation 23. Discography is not recommended for use in evaluating cervical spine conditions. See the Spinal Fusion section.
Recommendation 24. Electromyography and nerve conduction studies are recommended for patients with suspected neural involvement and persistent symptoms that are unresponsive to initial conservative treatment.
Recommendation 25. Somatosensory evoked potentials may be used to evaluate myelopathy, neurogenic bladder, and sexual dysfunction, but it is not recommended to identify radiculopathy.
Recommendation 26. Surface electromyography and current perception threshold evaluation are not recommended.
Evidence Tables.
Table 1. Evidence Table: Self-reported Body Pain Diagrams in Describing Neck Pain | ||
Summary: Pain diagrams, either manual or computerized, reliably identify pain location. | ||
Some evidence | Evidence statement | Design |
Using a computer program (electronic body surface estimation method) to measure pain distribution was found to have both high intra- and inter-examiner reliability in patients with chronic nonmalignant pain. | Systematic review | |
A body diagram, in which the patients use a pencil to shade in painful areas of the body, has acceptable reliability for designating the regions in which their pain is felt. | Systematic review | |
Table 2. Evidence Table: Physical Examination Findings and Neck Pain | ||
Summary: The findings on physical examination may be clinically suggestive of neurologic compression. | ||
Some evidence | Evidence statement | Design |
Spurling's test, traction/neck distraction, and Valsalva demonstrate reasonable specificity. With high suspicion for nerve root compression, they are helpful to clinically rule in radiculopathy. | Systematic review | |
Table 2 continued. Evidence Table: Physical Examination Findings and Neck Pain | ||
Some evidence cont. | The upper limb tension test should be done with finger and wrist extension. When performed in this manner and with a low index of clinical suspicion, a negative upper limb tension test may be helpful to rule out radiculopathy. | Systematic review |
Table 3. Evidence Table: Occupational Risk Factors for Neck Pain | ||
Summary: Neck pain is caused by a combination of workplace factors (e.g., poor workstation ergonomic design, work posture, and workplace activities) and personal factors (e.g., age, previous musculoskeletal pain, and low physical fitness). Prolonged neck flexion while performing repetitive or precision work and performing tasks that require sustained trapezium activity may result in neck pain. | ||
Strong evidence | Evidence statement | Design |
Neck pain in the workplace is multifactorial, and a combination of workplace and individual factors is necessary to cause neck pain. | Systematic review | |
Some evidence | Evidence statement | Design |
Repetitive or precision work, accompanied by prolonged neck flexion, are likely risk factors for neck pain in the workplace. | Systematic review | |
Sustained trapezius muscle activity predicts later neck and shoulder pain. | Cohort study | |
Table 4. Evidence Table: Interdisciplinary Neck Pain Care | ||
Good evidence | Evidence statement | Design |
Interdisciplinary programs that include screening for psychological issues, identification of fear-avoidance beliefs and treatment barriers, and establishment of individual functional and work goals will improve function and decrease disability. | RCT | |
Table 5. Evidence Table: Imaging Findings and Neck Pain | ||
Summary: Imaging findings occur frequently in asymptomatic patients and therefore are a poor indicator for clinically significant pathology. | ||
Table 5 continued. Evidence Table: Imaging Findings and Neck Pain | ||
Some evidence | Evidence statement | Design |
The majority of workers over 60 show evidence of disc degeneration on cervical spine MRI, and posterior disc protrusions are present in the majority of asymptomatic workers over 40 years of age. | Cohort study | |
Asymptomatic subjects of all ages frequently show common degenerative changes in the cervical and lumbar spine as seen on MRIs. These changes are more common with increasing age. The cervical and lumbar spine are equally affected, suggesting that disc degeneration occurs in tandem in the lumbar and cervical spine. | Cohort study | |
7 CCR 1101-3-17-08-4