Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Dr. Balentine received his undergraduate degree from McDaniel College in Westminster, Maryland. He attended medical school at the Philadelphia College of Osteopathic Medicine graduating in1983. He completed his internship at St. Joseph's Hospital in Philadelphia and his Emergency Medicine residency at Lincoln Medical and Mental Health Center in the Bronx, where he served as chief resident.
Pain varies from person to person and is hard to measure. The doctor will rely on your description of your symptoms to better quantify your pain. You may be asked to rate your pain on a scale from
one to 10 with 10 as the worst pain. Although difficult to generalize, the following types of symptoms usually predict the types of anatomic structures injured:
Cramping, dull, aching pain may indicate that muscles may be injured.
Sharp, shooting pain could be injury to a nerve root.
Sharp, lightning-like pain may indicate that a nerve is injured.
Burning, stinging pressure may indicate nerve injury.
Deep, nagging, dull pain could be injury to a bone.
Sharp, intolerable, severe pain could indicate a fracture.
Throbbing, diffuse pain may be injury to blood vessels.
History
As well as trying to determine the severity of your pain, the doctor will focus on several other key areas:
Your age
How you were injured
Previous injuries
Your type and usual level of activities
The presence (or absence) of head impact and loss of consciousness
The way your symptoms developed
Factors that make you feel better or worse
Radiation of the symptoms away from the neck and the
presence of any symptoms that suggest nerve problems such as weakness, altered
sensation, tingling, and (particularly ominous) any bowel or bladder
dysfunction
Physical examination
Physical evaluation for neck strain may be divided into the phases of observation, touching your muscles and other structures in your neck (palpation), examination of the blood vessels in your neck, nerve testing and, finally, an assessment of your ability to move. In most cases of trauma involving a significant mechanism of action, a complete examination is usually not completed until a set of preliminary X-rays has confirmed the lack of fractures (broken bones) and dislocations of the cervical spine.
Observation
The doctor may wish to see you walk into the examination room and may also observe
for any difficulty undressing yourself.
Typically, your posture, gait, facial expression, willingness to move for examination, and ease of movement will be assessed.
The doctor will be interested to see whether your
head is rotated to one side. This usually indicates muscle spasm of the neck (called torticollis).
The position of your chin and head will be noted as well as your habitual posture and the symmetry of the neck contour formed by the trapezius muscle.
The posture of your head and neck may also be checked while you sit and then stand. Any differences will be noted.
Your shoulders will be checked to see if they are level when you are relaxed. Asymmetry often indicates muscle spasm.
Doctor observation is often also sufficient to lead to a suspicion of a problem causing an inadequate blood supply (ischemia) in one of
the upper limbs. Your doctor will examine the blood vessels in your neck by
feeling the pulses to assess for briskness of upstroke and fullness, and the
presence of any abnormal sounds heard with a stethoscope placed over the blood
vessel (auscultation). The doctor will also look for any evidence of any
increased pressure in the neck veins (distended or bulging jugular veins). The
doctor will check your trachea, particularly if you have any symptoms of hoarseness.
The doctor will also palpate your head, neck,
shoulders, and possibly other areas. Palpation is useful in detecting
differences in tissue tension, texture, and thickness, tenderness, and abnormal sensation. In addition, differences in temperature and dryness (or excessive moisture) become readily apparent. Tremor (shaking) and muscle twitches may also be checked in this manner.
The doctor will perform neuromuscular testing to determine whether you have any injuries to the nerves and joints in your neck. These tests typically involve moving your body both passively and actively, to assess for strength, range of motion, and any loss of sensation.
The combination of a detailed history, physical examination, and one or more imaging procedures should enable your doctor to exclude, or identify, any serious injury to your neck and thereby plan your treatment.
Diagnostic imaging
Many different types of imaging studies are available.
Plain X-rays are still the primary means of looking
for trauma to bones involving the cervical spine. They have the advantages
of low cost, wide availability, and good anatomic resolution. X-rays do not give a good image of soft tissue structures (muscles and ligaments).
The technician will customarily obtain multiple views.
The actual reading of cervical spine radiographs is
a science in itself and may be performed by any knowledgeable doctor with
the backup of a radiologist.
This painless, noninvasive technique produces cross-sectional images of tissues.
CT scans offer far better tissue contrast resolution when compared to plain
X-rays and are excellent for displaying bony architecture, although soft tissues are seen less well.
It is useful in assessing for complex fractures and
dislocations, disk protrusions, disease of the joints of the vertebrae, and spinal stenosis (a narrowing of the space containing the spinal cord).
Myelography (spinal cord imaging)
In this technique, a water-soluble contrast dye is injected into the epidural space via lumbar puncture and allowed to flow to different levels of the spinal cord.
Plain X-rays, or more commonly CT scan, are then performed, to indirectly visualize structures outlined by the dye.
This technique is very sensitive at detecting disk
disease, disk herniation, nerve entrapment, spinal stenosis, and tumors of the spinal cord. Side effects of the procedure include headache, dizziness, nausea, vomiting, and seizures.
MRI is another noninvasive, painless imaging
technique used to obtain images of bone and soft tissue. It uses magnetic
fields and is based on detecting the effect of a strong magnetic field on
hydrogen atoms contained in water.
So-called T1 images show very good anatomic detail, whereas T2 images demonstrate any soft tissue problems that alter tissue water content. Both offer excellent tissue contrast and have no known side effects, although claustrophobia is a problem in some people.
MRI cannot be used for people with implanted or other metallic foreign bodies not firmly fixed to bone but is reportedly safe with prosthetic joints and internal fixation devices. It is often preferred over myelography
for the assessment of disk disease because it is noninvasive.
Diskography
This involves the injection of radiopaque dye into the center of an intervertebral disk (nucleus pulposus), using radiographic guidance, and may be used to determine disk disruptions.
It is uncommonly performed but is sometimes used in cases where the precise cause of your symptoms is difficult to ascertain to see whether the injection brings on your symptoms.
This technique uses a very short-lived radioactive isotope (technetium 99m) administered by IV and are absorbed by actively metabolizing bone
tissue during bone turnover. The amount of uptake is proportional to the
amount of metabolism.
Localized "hot spots" may then be visualized through the use of a special camera, which can detect the gamma rays emitted by the radioisotope. This technique is very sensitive for detecting fractures or other bone problems.
