Neck Pain

Essentials of Diagnosis

• Most chronic neck pain is caused by degenerative joint disease and responds to conservative treatment

• Cervical radiculopathy symptoms can be referred to the shoulder, arm, or upper back

• Whiplash is the most common type of traumatic injury to the neck

• Poor posture is often a factor for persistent neck pain

General Considerations

• Most neck pain, especially in older patients, is due to mechanical degeneration involving the cervical disks, facet joints, and ligamentous structures

• Many degenerative conditions of the neck result in cervical canal stenosis or neural foraminal stenosis, sometimes affecting underlying neural structures

• Cervical radiculopathy, usually involving the C5–C7 disks, can cause neurologic symptoms in the upper extremities

• Other causes of neck pain

  • Rheumatoid arthritis

  • Fibromyalgia

  • Osteomyelitis

  • Neoplasms

  • Polymyalgia rheumatica

  • Compression fractures

  • Pain referred from visceral structures (eg, angina)

  • Functional disorders

• Amyotrophic lateral sclerosis, multiple sclerosis, syringomyelia, spinal cord tumors, and Parsonage-Turner syndrome (brachial neuritis) can mimic myelopathy from cervical arthritis

Symptoms and Signs

• Headaches

• Shoulder pain

• Pain may be limited to the posterior region or, depending on the level of the symptomatic joint, may radiate segmentally to the occiput, anterior chest, shoulder girdle, arm, forearm, and hand

• May be intensified by active or passive neck motions

• The general distribution of pain and paresthesias corresponds roughly to the involved dermatome in the upper extremity

• Patients with discogenic neck pain often complain of pain with flexion, which causes cervical disks to herniate posteriorly

• Extension of the neck usually affects the neural foraminal and facet joints of the neck

• Rotation and lateral flexion of the cervical spine should be measured both to the left and the right

• Radiating pain in the upper extremity is often intensified by hyperextension of the neck and deviation of the head to the involved side

• Limitation of cervical movements is the most common objective finding

• Neurologic signs depend on the extent of compression of nerve roots or the spinal cord

• Compression of the spinal cord may cause long-tract involvement resulting in paraparesis or paraplegia

ACUTE OR CHRONIC CERVICAL MUSCULOTENDINOUS STRAIN

• Acute episodes are associated with pain, decreased cervical spine motion, and paraspinal muscle spasm, resulting in stiffness of the neck and loss of motion

• Local tenderness is often present in acute but not chronic strain

HERNIATED NUCLEUS PULPOSUS

• Rupture or prolapse of the nucleus pulposus of the cervical disks into the spinal canal causes pain that radiates to the arms at the level of C6–C7

• When intra-abdominal pressure is increased by coughing, sneezing, or other movements, symptoms are aggravated, and cervical muscle spasm may often occur

• Neurologic abnormalities may include decreased biceps and triceps deep tendon reflexes and decreased sensation and muscle atrophy or weakness in the forearm or hand

ARTHRITIC DISORDERS

• Osteoarthritis of the cervical spine is often asymptomatic but may cause diffuse neck pain, radicular pain, or myelopathy

• Myelopathy develops insidiously and is manifested by numb, clumsy hands

• Some patients also complain of unsteady walking, urinary frequency and urgency, or electrical shock sensations with neck flexion or extension (Lhermitte sign)

• Weakness, sensory loss, and spasticity with exaggerated reflexes develop below the level of spinal cord compression

Differential Diagnosis

• Acute or chronic cervical musculotendinous strain

• Herniated nucleus pulposus

• Degenerative arthritides (eg, osteoarthritis)

• Inflammatory arthritides (eg, rheumatoid arthritis, ankylosing spondylitis)

• Infections (eg, meningitis, osteomyelitis)

• Cancer (eg, cervical spine metastases)

• Fibromyalgia

• Thoracic outlet syndrome

Imaging Studies

• Radiographs

  • Results are completely normal in many patients who have suffered an acute cervical strain

  • Loss of cervical lordosis is often seen but is nonspecific

  • Comparative reduction in height of the involved disk space and osteophytes are frequent findings when there are degenerative changes in the cervical spine

• CT scanning is the most useful when bony abnormalities, such as fractures, are suspected

• MRI is the best method to assess the cervical spine since the soft tissue structures can be evaluated

• CT and MRI should be obtained urgently if the patient has signs of cervical radiculopathy with motor weakness

Diagnostic Procedures

• A detailed neurovascular examination of the upper extremities should be performed, including

  • Sensory input to light touch and temperature

  • Motor strength testing, especially the hand intrinsic muscles (thumb extension strength [C6], opponens strength (thumb to pinky) [C7], and finger abductors and adductors strength [C8–T1])

  • Upper extremity reflexes (biceps, triceps, brachioradialis)

• True cervical radiculopathy symptoms should match an expected dermatomal or myotomal distribution

• EMG is useful in order to differentiate peripheral nerve entrapment syndromes from cervical radiculopathy

• The Spurling test

  • Involves the patient rotating and extending the neck to one side (Table 41–4)

  • Reproduction of the cervical radiculopathy symptoms is a positive sign of nerve root compression

• Palpation of the neck is best performed with the patient in the supine position

Medications

• NSAIDs are commonly used and opioids may be needed in cases of severe neck pain

• Muscle relaxants (eg, cyclobenzaprine 5–10 mg three times daily orally) can be used short-term if there is muscle spasm or as a sedative to aid in sleeping

• Acute radicular symptoms can be treated with neuropathic medications (eg, gabapentin 300–1200 mg three times daily orally), and a short course of oral prednisone (5–10 days) can be considered (starting at 1 mg/kg)

Surgery

• Surgery is successful in reducing neurologic symptoms in 80–90% of cases but is still considered as treatment of last resort

• Common surgeries for cervical degenerative disk disease include

  • Anterior cervical discectomy with fusion

  • Cervical disk arthroplasty

• Cervical spine surgery does not have clear evidence of benefit over conservative treatment

Therapeutic Procedures

• Neck stretching, strengthening and postural exercises in physical therapy have demonstrated benefit in relieving symptoms

• A soft cervical collar can be useful for short-term use (up to 1–2 weeks) in acute neck injuries

• Chiropractic manual manipulation and mobilization can provide short-term benefit for mechanical neck pain

• Specific patients may respond to use of home cervical traction

• Cervical foraminal or facet joint injections can also reduce symptoms

When to Refer

• Patients with severe symptoms with motor weakness

• Surgical decompression surgery if the symptoms are severe and there is identifiable, correctable pathology