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Neck pain is a common musculoskeletal symptom and accounts for a sizeable portion of the 9.3 million physician visits annually in the United States for soft tissue disorders. Of those individuals with neck pain, 81% were between the ages of 18 and 64 years as reported by the United States Bone and Joint Decade in 2008. Mechanical disorders cause 90% of neck pain episodes. Mechanical neck pain may be defined as pain secondary to overuse of a normal anatomic structure or pain secondary to trauma or deformity of an anatomic structure (Figure 9–1). Mechanical disorders are characterized by exacerbation and alleviation of pain in direct correlation with particular physical activities. Neck pain due to mechanical disorders decreases within 2–4 weeks in over 50% of patients; symptoms usually resolve within 2–3 months.

Figure 9–1.

Schematic representation of a lateral view of the mid-cervical spine (A) and the superior aspect of C5 (B). The inferior articular processes from synovial-lined facet joints (also called apophyseal joints) with the superior articular processes of the vertebra below. The uncinate processes or posterolateral lips located on the superior aspect of the vertebral bodies interact with the inferolateral aspects of the vertebral body above, forming the small, non-synovial-lined uncovertebral joints (also referred to as the joints of Luschka). The spinal cord lies within the vertebral foramen formed by the vertebral body anteriorly, the pedicles laterally, and the laminae posteriorly. The cervical nerve roots course along “gutters” formed by the pedicles and exit through an intervertebral foramen. The vertebral artery passes through the transverse foramen. (Reproduced, with permission, from Polley HF, Hunder GS. Rheumatologic Interviewing and Physical Examination of the Joints, 2nd ed. WB Saunders; 1978.)

The goal of the initial evaluation is to differentiate patients with probable mechanical disorders from those with neck pain that requires more thorough immediate evaluation (Figure 9–2). A history should be taken and an examination should be performed in all patients with new-onset neck pain. The neurologic examination should determine whether there are any signs of cervical nerve root or cervical cord involvement (ie, spastic weakness, hyperreflexia, clonus, and positive Babinski signs).

Figure 9–2.

The initial evaluation of the patient with neck pain.

Diagnostic radiographic or laboratory tests are not necessary during the initial evaluation of patients with probable mechanical neck pain. These tests, however, are indicated for patients whose history and physical findings suggest persistent compression of the spinal cord or nerve roots or raise the possibility of neck pain as a component of an underlying systemic disease.


The history should establish the character, onset, location, radiation, aggravating and alleviating factors, intensity, and chronologic development of neck ...

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