Neck Pain

Key Features

Essentials of Diagnosis

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

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

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

• 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

Clinical Findings

Symptoms and Signs

• Neck pain

  • May be limited to the posterior region

  • May radiate segmentally to the occiput, anterior chest, shoulder girdle, arm, forearm, and hand depending on the level of the symptomatic joint

  • 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

• Limitation of cervical movements is the most common objective finding

Diagnosis

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

• 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

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

Diagnostic Procedures

• The patient's posture should be assessed, checking for

  • Shoulder rolled forward or head forward posture

  • Scoliosis in the thoracolumbar spine

• 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 ...