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 Case
#39 “My Neck is Killing Me!” by Charlene Babcock Irvin, MD
A 33 y/o man presents with neck pain. The
pain started last night. He was working at a
discount toy store, and while getting a box
from a high shelf, he looked up, and
experienced a sudden and severe pain in the
back of his neck. He immediately put the box
down and called his supervisor for help. He
was taken to another local hospital where
x-rays were reported as normal. He followed
up with his primary doctor earlier today,
and was given pain medication and a few days
off work. He now comes in because the pain
medication from his doctor isn’t working. He
feels nauseous from the pain, but no
vomiting. The pain is located in the middle
of the neck posteriorly, and gets worse if
he moves his neck. There is no radiation.
Nothing makes it feel better. It was worse
when it first started, but he still rates it
at 8/10. He has never had pain like this
before, and no previous neck problems.
ROS: No fevers, cough, sore throat, nasal
congestion, change in vision, numbness,
weakness, chest pain, abdominal pain. No
rashes.
PMH: Negative. Takes no meds, no
hospitalizations, no surgeries.
SH: Denies drugs, drinks alcohol on the
weekends. Has two small children and is
married.
FH: Negative except parents have
hypertension.
PE: Obese diaphoretic male lying still on
cot.
BBP: 128/82 P=98 RR=20 Temp: Afebrile Sat
98% room air
HEENT: PERRL, normal Fundi, no sinus
tenderness, TM clear, Orophranx normal. Neck
supple, but patient complains of pain with
movement. Some mild tenderness is noted on
palpation to the cervical spine, but
palpation does not reproduce the pain. When
asked to point to where the pain is, the
patient points to C-1-C-4.
Heart: RRR normal
Lungs: Normal
Abd: Obese, normal
Ext: Normal
Neuro: CN II-XII normal, motor 5/5
throughout. Reflexes (brachial, patella)
normal. Babinski normal, sensation normal,
mental status: normal, cerebellar testing
(finger-nose) normal.
Because of the severe nature of the pain,
with reportedly normal c-spine x-rays, you
order a c-spine CT scan. Also, because it’s
not clear what is going on, and because of
his diaphoresis, you order some screening
labs. An IV is initiated, some fluids are
given, and IV morphine and Zophran for
pain/nausea are initiated.
The neck CT came back normal. Labs were all
normal. On re-evaluation of the patient, he
was feeling much better (sitting up, joking
with his wife about all the action in the
ED). He was no longer diaphoretic and
appeared very comfortable.
Because it’s not clear what is going on, and
because this patient looked ill on
presentation, I consulted a neurosurgeon. I
at least needed to arrange close follow up,
and it’s not unusual for the consultant to
suggest additional investigations. I find I
frequently learn something from a
consultant, and am not embarrassed to ask
for their opinion when the case is not
straightforward. After describing the
history and workup, he suggests two
additional tests that should be done before
the patient gets discharged. The second of
which was positive and the patient was
admitted.
1. What did this patient have?
2. What is the scoring system and why is it
useful? What is the mortality rate for this
condition?
3. When this is missed initially, how long
before a catastrophic presentation?
Click here for answers and to respond
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