Neck Pain

Overview

Although neck pain is not nearly as common as low back pain, approximately 50% of people will experience a significant episode of neck pain in their lifetime. Neck pain is more common in sedentary individuals, especially those who work at a desk and/or computer station. Fortunately, the prognosis for patients with neck pain is excellent, since well over 90% of patients with neck pain improve with conservative (non-surgical) treatment.

Causes

There are many causes of neck pain, which can be categorized as mechanical, degenerative, inflammatory, infectious, traumatic, oncologic (tumor or cancer), congenital/developmental, idiopathic, or psychogenic. Within each of these categories, there are a number of specific diagnoses that can cause neck pain with or without associated symptoms. Despite neck pain being quite common, the actual cause is not determined in the majority of cases. This may be, in large part, due to the fact that most patients have improvement of their pain before visiting their physician and/or obtaining diagnostic tests. A strain or sprain of the neck is extremely common, especially following a motor vehicle accident or traumatic event.

Symptoms

Although most patients with a cervical spinal disorder present with some degree of axial neck pain, this may not be the chief complaint or problem. Patients with a simple muscle strain or ligament sprain will often have only isolated neck pain and spasm, whereas a patient with a large herniated disc with spinal nerve compression may have severe radiating arm pain with little or no neck pain. Patients with cervical spinal stenosis and myelopathy may or may have neck pain, but frequently have weakness and numbness in the upper and/or lower extremities with difficulty walking and loss of fine motor coordination. Spine infections or tumors may present with constitutional symptoms such as fever, chills, weight loss, and/or night pain. Patients with rheumatoid arthritis or other inflammatory conditions are at high risk for developing neck problems and may have multiple areas of musculoskeletal pain, swelling, stiffness, and deformity.

Physical Findings

The physical findings for most neck disorders often include localized tenderness and decreased cervical range-of-motion. Skin lesions or wounds, swelling, or ecchymosis (bruising) are typically seen only with traumatic injuries, infections, or possibly tumors. Neurologic abnormalities (such as arm/hand muscle weakness or numbness) may be present with a variety of serious spinal disorders, and indicate significant spinal cord or nerve root compression. Abnormal balance or coordination when standing and walking can signify significant disorders of the spinal cord or brain. Sudden onset of bowel or bladder dysfunction can also be indicative of spinal cord compression.

Imaging Studies

X-rays are commonly obtained in the early phases of neck pain evaluation, especially if the pain began suddenly or occurred because of a traumatic injury. X-rays of the neck and spine are simple, cost-effective imaging tests that can be used to evaluate bone quality (checking for osteoporosis), spinal alignment, and check for a spine fracture. A magnetic resonance imaging (MRI) study is routinely ordered to evaluate for a disc injury, spinal cord/nerve compression, or spinal tumor or infection. A Computed Tomography (CT) scan is used to more accurately identify and diagnose bone lesions. A myelogram may be performed by itself or in conjunction with a CT scan to evaluate neurologic compression, and involves injecting dye into the spinal canal (within the thecal sac, where the nerves are contained) and taking x-rays and/or CT images of the spine afterward. A bone scan is a special test that utilizes a radionucleotide tracer, which is injected intravenously, to help identify bone lesions such as cancer, tumors, infections, or fractures. A bone density test is noninvasive and checks the mineral density of bone (usually of the spine, hip, and wrist areas) to determine if osteoporosis is present.

Laboratory Tests

Simple blood tests may also be useful in the evaluation of neck pain. A Complete Blood Count with differential (CBC), erythrocyte sedimentation rate (ESR), and C-Reactive Protein (CRP) is ordered if infection is suspected. Calcium, Phosphorus, Vitamin D, Parathyroid Hormone, and Alkaline Phosphatase levels are checked when metabolic disorders are suspected. Titers for Rheumatoid Factor (RF), ANA, and HLA-B27 are checked when the patient is suspected of having rheumatoid arthritis, ankylosing spondylitis, or other rheumatologic disorder. Serum Protein Electrophoresis and Urine Protein Electrophoresis is performed to detect multiple myeloma, the most common type of bone cancer of the spine.

Electrophysiology tests such as electromyelography and nerve conduction (EMG/NCV) studies are routinely performed by a neurologist to distinguish the precise location and severity of nerve damage.

Diagnosis

Mechanical Strain, Sprain, Annular Tear, Herniated Nucleus Pulposis
Degenerative Degenerative Disc Disease, Facet Arthropathy, Spinal Stenosis
Inflammatory Rheumatoid Arthritis, Ankylosing Spondylitis
Infectious Discitis, Osteomyelitis, Epidural Abcess (Pyogenic, Tuberculous, Fungal)
Traumatic Fracture, Subluxation, Dislocation
Oncologic Benign or Malignant Spine Tumor, Metastatic Spine Tumor
Congenital Klippel-Feil syndrome
Idiopathic Unknown
Psychogenic Psychiatric Disorders with manifestation of neck pain

A differential diagnosis (list of possible diagnoses) is developed before, and especially after, all of the symptoms, physical findings, imaging studies, and laboratory tests are analyzed. Often, there is one diagnosis that can be firmly established if all of the appropriate examinations and studies were performed.

Treatment Options

Treatments for neck pain, like many medical conditions, can be conservative (non-operative) or surgical. Most conditions affecting the spine are self-limited, and improve or completely resolve with conservative treatments. Patients are generally recommended for the most conservative, noninvasive treatments first. Spinal injections and surgical treatments are only considered if the diagnosis is amenable to surgery and non-operative treatments have failed. Rarely, some spinal conditions are more serious (fractures, cancer, etc.) and require immediate surgical management.

Conservative

  • Rest or Activity Reduction
  • Oral Medications
  • Topical (Ice packs, heat, ointments, etc.)
  • Orthotics (Back brace, corset, etc.)
  • Yoga or Pilates exercises
  • Massage
  • Physical Therapy
  • Chiropractic Manipulation
  • Modalities (Ultrasound, Phonophoresis, Iontophoresis)
  • Sauna or Whirlpool
  • TENS
  • Interferential Unit
  • Traction
  • Acupuncture
  • Facet Joint Injections
  • Epidural Steroid Injections

Surgical

  • Anterior Cervical Discectomy and Fusion
  • Anterior Cervical Corpectomy and Fusion
  • Microscopic Posterior Foraminotomy
  • Cervical Laminectomy
  • Cervical Laminaplsty
  • Posterior Cervcial Fusion
  • Anterior or Posterior Cervcial Osteotomy
  • Artificial Disc Replacement

Selected Bibliography

Bovim G, Shrader H, et al: Neck pain in the general population. Spine 1994;19:1307.

Gore DR, Sepic SB: Neck pain: a long-term follow-up of 205 patients. Spine 1987;12:1.

Guez M, Hildingsson C, et al: The prevalence of neck pain: a population-based study from northern Sweden. Acta Orthop Scand 2002;73:455.

Lees F, Turner J: Natural history and prognosis of cervical spondylosis. BMJ 1963;2:1607.

Webb R, Brammah T, et al: Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population. Spine 2003;28:1195.

White A, Southwick W, et al: Relief of pain by anterior cervical spine fusion for spondylosis. J Bone Joint Surg Am 1973;55:525.

William J, Allen M, Harkess J: Late results of cervical discectomy and interbody fusion: some factors influencing the results. J Bone Joint Surg Am 1968;50:277.