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Home Books The Patient History: An Evidence-Based Approach to Differential Diagnosis, 2e

Chapter 51. Neck Pain

John D. Goodson, MD

A 57-year-old science teacher presents with right-sided neck pain. He describes intense discomfort in the back of his neck and upper back along the medial aspect of his right scapula. The pain has been present for 10 days and began after he had installed new overhead lighting in his basement workshop.

  • What repetitive positions are most likely to aggravate the neck?
  • What is the pattern of referred pain from cervical radicular root irritation?
  • Which muscle groups are affected by cervical nerve root impingement?
  • What symptoms require urgent imaging and/or surgical consultation?

Neck pain can be categorized by location and onset. Most neck pain originates in the back (posterior) portion of the neck in the muscular, neurologic, or bony structures. Patients may also describe pain as most intense in the neck or shoulders or the upper extremities along the distribution of a cervical nerve root.1,2 Pain in the back of the neck is generally axial, meaning along the midline or the paraspinous region, or radicular, meaning radiating to the shoulder or arm on one side or both sides.

Pain arising from muscular, vascular, and glandular structures, as well as the trachea and esophagus, commonly refers to the front (anterior portion) of the neck. Finally, pain may be referred from other parts of the body such as the chest, heart, and esophagus.

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Anterior neck painPain in the front of the neck. May originate from cervical lymph nodes, sternoclavicular muscles, trachea, pharynx, carotid arteries, thyroid, or esophagus. Referred pain from the heart, lungs, or pericardium generally occurs in the anterior neck.
CarotidyniaPain in the anterior neck overlying the carotid artery. The pulsation of the artery can generally be felt.
Cervical radiculopathyPain or numbness in the distribution of one or more of the cervical nerve roots (see Figure 51–1 and box titled "Motor Function for Select Cervical Spine Myotomes"). Patients may report little or no neck pain per se. Focal weakness may also occur. Impingement can result from disk herniation or from nerve root entrapment due to degenerative arthritis of the facet joints.
Complex regional pain syndromeA combination of pain, swelling, and dysautonomic symptoms such as flushing or warmth in an anatomic region such as an extremity or part of an extremity (see Chapter 53).
DermatomeThe cutaneous sensory distribution of an individual spinal nerve bundle or root.
Neck stiffnessA generalized decrease in neck mobility. This usually results from facet joint arthritis or neck injury with associated neck muscle or trapezius muscle spasm from nerve root irritation. Other causes include polymyalgia rheumatica, localized infection, and meningitis.
Occipital neuralgiaPain located at the base of the skull at the juncture of the occiput and the first cervical vertebral body (atlas). Pain may radiate to the back of the head in the distribution of the second cervical nerve root. Pain is commonly referred to ...

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