Neck pain (경부통)

The Root of Ambulatory Care (외래 진료 지침서) 전체 목록 보기
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The Root of Ambulatory Care

The Root of Ambulatory Care

  • 저 자 : 이진우
  • 출 판 : 군자출판사
  • 페이지수: 543면

이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
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KEYWORDS: ..전체 성인의 50%는 일생에 한 번 이상 경부 통증을 경험한다. - Cervical spondylosis(osteoarthritis) : Individuals > 50years, history of OA (osteophytes), limited motion or morning stiffness - Acute neck sprain : paravertebral discomfort relieved with rest and aggravated with activity - Cervical radiculopathy : due to herniated nucleus pulposus ; a younger patient with an abnormal upper extremity neurologic examination due to cervical spondylosis ; an older patient with limited motion and pain on extension - Cervical myelopathy : urinary dysfunction with global sensory changes, weakness, and an abnormal gait - Trauma - Chronic pain syndrome - Rheumatoid arthritis - Torticollis : usually painless if congenital, usually painful if acquired - Referred pain : especially from the shoulder, diaphragm, apical lung, heart, and aorta (tempromandibular joint pain, bursitis, tendonitis, arthritis of shoulder, reflex sympathetic dystrophy, thoracic outlet syndrome etc) ..In most patients, a definite cause of neck pain cannot(and need not) be established, and the pain is attributed to neck strain or cervical spondylosis. ..기계적 손상 시 nerve root나 spinal cord 손상이 없이도 어깨나 윗쪽 팔로 통 증이 종종 방사된다. 반면 아랫쪽 팔까지 내려오는 통증, 힘빠짐, 감각마비, 지각이상 등이 있다면 cervical root irritation을 의심해야 한다. Neck pain < Normal Neck Range of Motion > ▶ Rotation : 60~90 degrees ▶ Flexion 60~90 degrees ▶ Extension : 60~90 degrees ▶ Lateral flexion(side-bending) : 30~60 degrees ROM normally decreases with age. Loss of motion is common in acute nonspecific and chronic mechanical neck pain. 1. Duration, onset, and course of pain? → Most neck pain lasts days to a few weeks, is non-radiating, and is influenced by movement and position. 2. Trauma? → 외상이라면 우선적으로 목을 움직이지 않도록 고정시키고 방사선 검사를 먼저 시행해 골절, 부종, 출혈 등의 손상 정도를 파악해야 한다. 3. Character of pain and any radiation? → Cervical spondylosis pain may radiate short distances in a fairly constant, achy, nondermatomal fashion. But radiculopathy pain is intermittent, sharp, and dermatomal and can be associated with numbness and weakness. 4. Better or worse with certain activities, movements, relieved by rest? → Pain improved by activity suggests a spondyloarthropathy. Pain not relieved by rest or that is progressive suggests infection or neoplasm. 5. Loss of bowel or bladder control, numbness or weakness? → Bowel or bladder dysfunction or lower extremity numbness, weakness, or ataxia suggests myelopathy. 6. Other medical history? → Patients with RA are prone to instability. Patients with ankylosing spondylitis are prone to fracture with trivial trauma. ..일반적으로 검사실 검사는 필요하지 않으며, 병력청취와 이학적 검사상 진단 이 명확하지 않을 때 고려해 볼 수 있다. 245 The Root of ambulatory care Key questions Key test Neck pain Spurling test ▶ Spurling test는 머리를 누른 상태에서 이환된 쪽으로 돌릴 때 이환된 쪽 팔에 cervical radiculopathy 증 상이 나타나는 검사로, 높은 특이도를 가지지만, 민감도는 떨어진다. 만일 단순히 목만 불편한 증상을 호소 한다면 비특이적인 기계적 손상을 시사한다. Radiographic evaluation Canadian Cervical Spine rules 1. Is there one high-risk factor that mandates immobilization ..Age ≥ 65 years old, or dangerous mechanism (fall from 1m or greater, axial load to head, motorized recreational vehicles, bicycle collision, or motor vehicle collision with high speed, rollover, or ejection) ..Numbness/tingling in extremities 2. Is there one low-risk factor to allow safe assessment of range of motion ..Simple rear-end motor vehicle collision ..Ambulatory at any time at scene ..No neck pain at scene ..Absence of midline C-spine tenderness 3. Is patient able to voluntarily actively rotate neck 45 degrees to the left and right when requested, regardless of pain? An answer “yes”to the first question or “No”to the second or third question requires radiography. 1. C-spine AP/lateral (oblique/open mouth view) 2. CT/MRI - 1개월 이내의 합병증이 없는 경부 통증의 경우는 고려하지 않는다. 3. EMG/NCV ..대체로 Neck pain은 self-limited 이며 70%는 1달 이내 소멸되며 심각한 질환이 배제되면 치료는 보존적으로 한다. 하지만 약 10%의 acute neck pain환자는 만성으로 진행하며, 5%에서는 심각한 disability를 가진다. 247 The Root of ambulatory care ..Many asymptomatic individuals have disk degeneration, herniated disks, or foraminal stenosis by MRI. ▶ Cervical radiculopathy - Nonpharmacologic 1. Relative rest : may use cervical pillow, soft cervical collar, traction. 2. Physical modalities : hot, ice, ultrasound 3. Isometric exercises : if pain lessens. Reassurance as to self-limited nature Problem. Instruction on proper body positioning during daily activities. Key treatment C2 2 3 4 5 6 7 C3 C4 C5 C6 C7 C8 Nerve Disk Muscle Weakness Root Level /Movement affected Reflex Paresthesia Site of Pain Shoulder C-5 C4/5 abduction, Biceps Shoulder Shoulder, lateral arm elbow fleaxion C-6 C5/6 Wrist extension/ Brachioradialis Thumb Deltoid, pronation and biceps rhomboid muscle areas C-7 C6/7 Elbow/ Triceps Middle finger Dorsolateral upper arm, finger extension superomedial angle of scapula C-8 C7/T1 Wrist/finger Triceps and Ring and Scapula, extension finger little finger ulnar site of upper arm Key treatment Neck pain ..Cervical radiculopathy환자를 수년간 관찰한 결과 치료에서 수술이 보존적 치 료보다 더 뛰어나다는 증거는 없다. - pharmacologic : Uncomplicated neck pain without severe neurologic deficit, including acute nonspecific neck pain and chronic mechanical neck pain 1. Acetaminophen ..Tylenol ER.. 650mg 1T, 1-2T tid 2. NSAIDs ..Brufen.. 200-600mg tid ..Naxen-F.. 500mg 1T bid~tid ..Voltaren 25mg 1T, 2T tid → 1T tid 3. Muscle relaxants ..Lioresal.. 1T tid ..Orpheryl.. 50mg 1T tid ..Naxen-F..- naproxen ..Voltaren..- diclofenac ..Lioresal.. - Baclofen ..Orpheryl..- orphenadrine < Red flags in neck pain > ▶ Fracture : significant trauma, osteoporosis history ▶ Infection : fever, alcohol, or drug abuse ▶ Tumor : history of cancer, unexplained weight loss (age > 50years), failure to improve with treatment ▶ Radiculopathy : lower extremity spasticity, bowel/bladder incontinence 249 The Root of ambulatory care 참고 문헌 Kevin M. McKown : Neck pain,Whiplash, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed).Philadelphia, Saunders, 2000, P 962-964, P 964-965 이용 : 경부 통증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 1142-1147 Michael P. Rowane, DO, MS, FAAFP, FAA. : Neck pain, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D.(ed).United States of America, The McGrwa-Hill Companies, Inc., 2005, P 295-300 Walter B. Greene, M.D.(ed) : Cervical Radiculopathy, Cervical Spondylosis, Cervical Sprain, in Essentials of Musculoskeletal Care. Rosemont, American Academy of Orthopaedic Surgeons, 2001, P 539- 541, P 542-544, P 545-547