Acute Neck Injury: Management

00:01 Now, that said, even for cervical radiculopathy, whiplash, the management of these different causes of neck pain really should follow about the same order because it's usually going to be a time-limited type of symptom.

00:15 More time will improve things.

00:18 I like acetaminophen as a first-line analgesic.

00:22 Why? Because it tends to be a little bit safer than others and usually better tolerated overall.

00:29 But it may not be enough and may not be as effective.

00:32 Therefore, think about NSAIDs, second line, not a great difference in terms of superiority of NSAIDs versus acetaminophen for musculoskeletal pain, but they might be more effective, but they do – you have to watch.

00:47 They can promote gastrointestinal bleeding.

00:49 You have to be careful in patients with heart disease or renal disease and taking NSAIDs too.

00:54 Muscle relaxants.

00:56 I really don't feel like there's much of a place for muscle relaxants.

00:59 They don't have a specific therapeutic target.

01:01 They do tend to make people very tired.

01:04 There is some risk of abuse associated with these agents as well.

01:08 So, don't really seem to have as much of a role.

01:11 Tramadol is a mu opioid receptor agonist, and so therefore does activate the natural opioid system.

01:23 It doesn't have the addictive potential as other opiates, but still has some addictive potential.

01:29 Can be used – particularly when used with acetaminophen, can be more effective than either alone.

01:36 And then opiates are really a last line.

01:39 Generally, Center for Disease Control in the US recommends they shouldn’t be used for more than seven days, most cases three days at most.

01:47 So, a short course of opiates for somebody who's really suffering, but not prolonging therapy down the road, I think, is important.

01:55 Other treatments that you may see recommended for neck pain.

01:58 Cervical collars are not helpful.

02:00 So, immobilization does not help and, therefore, that may come up on your exam.

02:03 Do not recommend it.

02:05 Home exercises, in and of themselves, they’re really – it’s unclear whether they're effective or not.

02:11 Physical therapy, on the other hand, can be effective for these patients.

02:14 I’ll usually reserve it for patients who are in a prolonged course of pain, more than several weeks where it just seems to be not getting better, yet they have got negative imaging studies.

02:24 Physical therapy can be a good option for those patients.

02:27 They may also think about spinal manipulation.

02:30 Overall, there really isn't enough data to recommend nor refute the use of spinal manipulations for cases of neck pain.

02:39 So, just a little bit more about whiplash.

02:41 About half of whiplash patients continue to have neck pain at one year.

02:45 So, if you're that severe that you have this – that severe stiffness, the severe muscle tension with headache that indicates whiplash after an acute injury, unfortunately, half will go on to continue to have symptoms, but there is a link between financial compensation or time off work and the duration of neck pain in these cases.

03:07 And with that – so with that, what we did today was really kind of differentiate a little bit of whiplash versus cervical radiculopathy.

03:14 We went through a very typical algorithm for the management of musculoskeletal pain that I'll probably return to a couple of times when we talk about other issues such as back pain, for example, or arthritis.

03:27 But I think that is very important to keep in mind as you move forward, starting with your more safe drugs with a proven record, and then really holding opiates out for the patients who need them and then trying to keep that course as short as possible.

03:44 So, hopefully, that was very helpful for you today.

03:46 Look forward to seeing you next time.