I enjoyed Ian Tsang's concise and useful lesson on neck pain.1 I was especially interested in Tsang's comment that consultation with a specialist may be necessary for patients with disabling or progressive neurologic problems. With or without neurologic deficits, patients often consider their neck condition to be disabling and progressive, so they and their family physicians are understandably anxious for a specialist's opinion. As a result, neurosurgeons are inundated with referrals for patients with neck (and back) problems, most of which do not involve the cervical nerve roots or the spinal cord and would not be appropriately treated by surgery.
Compounding this situation in Alberta is that many patients with chronic spinal pain turn to private MRI clinics, not uncommonly with their family physician's encouragement. A positive scan might fast-track a patient to a surgeon. However, few cervical spine MRI scans in middle-aged or older people are actually normal, and the reports often contain disturbing descriptions of degenerative changes, including bulging disks, osteophytes and “foraminal stenosis.” It is difficult to convince patients without neurological involvement that these changes are of quite uncertain significance.
If I can take the liberty of speaking for my specialty, our plea to family physicians would be to investigate and refer patients to surgeons judiciously. For example, cervical radiculopathies may be associated with a knot of pain in the parascapular region but are always associated with more pain in the limb than in the neck; upon careful investigation they are usually found to be associated with a neurologic deficit in the form of weakness, a depressed stretch reflex, dermatomal numbness or some combination of these. When these symptoms and signs persist for over a month without significant improvement, further investigations are appropriate. An almost identical strategy can be recommended for sciatica.2 If imaging demonstrates pathology that correlates with the clinical picture, referral to a surgeon should follow. One should also be on the lookout for red flags that should prompt more urgent investigation: fever, severe pain at rest, a history of cancer or risk factors for bacteremia, and signs of spinal cord compression. Overinvestigation and overreferral of patients with neck (and back) pain impede the assessment and treatment of the few patients who might benefit from surgical intervention.