Neck Pain

Epidemiology and Etiology

Epidemiology

Neck pain is a common symptom presenting to medical providers.

• The majority of adults develop neck pain at some point in their lifetime.
• Prevalence increases in middle age
• One of the leading causes of disability

Risk factors

• Occupation (repetitive work)
• Ergonomics
• Depression
• Sedentary lifestyle
• Previous history of trauma to the neck
• Smoking
• Genetic predisposition (Turner and Down syndromes)
• Concomitant lower back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain
• Rheumatic diseases

Etiology

Musculoskeletal conditions:

• Cervical strain, which can occur from:
  • Injury to cervical muscles
  • Poor posture
  • Sleeping habits
• Cervical spondylosis (nonspecific term for degenerative changes of the spine)
• Cervical discogenic pain (from disc degeneration)
• Whiplash injury (an acceleration–deceleration injury resulting from acute extension and flexion of the neck)
• Myofascial pain syndrome
• Cervical radiculopathy
  • Dysfunction of the spinal nerve root from inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, compression, or damage
  • May be caused by: 
    • Degenerative disease (e.g., foraminal stenosis, herniated disc)
    • Trauma
    • Nerve root infarction or avulsion
    • Tumor
    • Infection (e.g., herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox, Lyme disease Lyme disease Lyme disease is a tick-borne infection caused by the gram-negative spirochete Borrelia burgdorferi. Lyme disease is transmitted by the black-legged Ixodes tick (known as a deer tick), which is only found in specific geographic regions. Patient presentation can vary depending on the stage of the disease and may include a characteristic erythema migrans rash. Lyme Disease)
• Cervical spondylotic myelopathy 
  • Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord dysfunction or injury
  • Causes are similar to those for cervical radiculopathy
• Atlantoaxial subluxation or instability, which is usually associated with:
  • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis
  • Down syndrome Down syndrome Down syndrome, or trisomy 21, is the most common chromosomal aberration and the most frequent genetic cause of developmental delay. Both boys and girls are affected and have characteristic craniofacial and musculoskeletal features, as well as multiple medical anomalies involving the cardiac, gastrointestinal, ocular, and auditory systems. Down Syndrome

Nonmusculoskeletal conditions:

• Cardiovascular disease:
  • Angina
  • MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction
• Infection:
  • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
  • Epidural abscess
  • Discitis
  • Osteomyelitis Osteomyelitis Osteomyelitis is an infection of the bone that results from the spread of microorganisms from the blood (hematogenous), nearby infected tissue, or open wounds (non-hematogenous). Infections are most commonly caused by Staphylococcus aureus. Osteomyelitis
• Neurologic:
  • Tension headaches Tension headaches Tension headache is the most common of the primary primary headache disorders and one of the most common disorders presenting for medical evaluation worldwide. Tension headaches are generally described as bilateral, nonthrobbing, and of mild to moderate severity. There is no aura or other associated features. Tension Headaches
  • Chiari malformations Chiari Malformations Chiari malformations (CMs) are a group of central nervous system (CNS) conditions characterized by the underdevelopment of the posterior cranial fossa with subsequent protrusion of neural structures through the foramen magnum. Chiari Malformations
• Rheumatologic disease:
  • Polymyalgia rheumatica
  • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis
  • Ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis (also known as Bechterew's disease or Marie-Strümpell disease) is a seronegative spondyloarthropathy characterized by chronic and indolent inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Ankylosing Spondylitis
  • Fibromyalgia Fibromyalgia Fibromyalgia is a chronic pain syndrome characterized by widespread body pain, chronic fatigue, mood disturbance, and cognitive disturbance. It also presents with other comorbid symptoms such as migraine headaches, depression, sleep disturbance, and irritable bowel syndrome. Fibromyalgia
  • Giant cell arteritis Giant Cell Arteritis Giant cell arteritis (GCA), also known as temporal arteritis, is a type of large-vessel vasculitis that predominantly affects the aorta and its major branches, with a predilection for the branches of the carotid (including the temporal artery). Giant cell arteritis is defined by inflammatory leukocytes in the vessel walls leading to reactive damage, ischemia, and necrosis. Giant Cell Arteritis should be considered in a patient with: 
    • Neck pain
    • Headache
    • Jaw Jaw The jaw is made up of the mandible, which comprises the lower jaw, and the maxilla, which comprises the upper jaw. The mandible articulates with the temporal bone via the temporomandibular joint (TMJ). The 4 muscles of mastication produce the movements of the TMJ to ensure the efficient chewing of food. Jaw and Temporomandibular Joint claudication
    • Associated visual changes
• Malignancy: 
  • Metastatic disease
  • Apical lung tumor
• Thoracic outlet syndrome Thoracic outlet syndrome Thoracic outlet syndrome (TOS) is a broad term used for a spectrum of syndromes related to the general region of the thoracic outlet, which involves the compression or irritation of elements of the brachial plexus, subclavian artery, or subclavian vein. Thoracic Outlet Syndrome (TOS)
• Vertebral artery dissection
• GI:
  • Biliary disease
  • Esophageal disease

Diagnosis

The differential diagnoses related to neck pain is vast and can be narrowed on the basis of the history and physical examination.

• Imaging studies may not be indicated during the initial examination (< 6 weeks of symptoms).
• Exceptions:
  • Red flag signs and symptoms 
  • Serious injury

Imaging studies

• Imaging studies are considered, or indicated, in the following clinical scenarios:
  • Associated acute trauma
  • Serious or progressive neurologic findings
  • Constitutional signs and symptoms
  • History of malignancy
  • Infectious risk factors: 
    • IV drug abuse
    • Immunosuppression 
  • Positive Lhermitte’s sign
  • Persistent neck pain not responding to appropriate therapy
• Plain X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays can evaluate for:
  • Degenerative changes
  • Disc height loss
  • Malalignment
  • Fractures
  • Cervical spine instability
• CT:
  • Method of choice for fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures detection during trauma evaluations
  • Evaluation of bony anatomy and fractures
• MRI to evaluate abnormalities of: 
  • Soft tissues
  • Intervertebral discs
  • Spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord
  • Nerve roots

Additional studies

• Electromyography and nerve conduction studies: 
  • Not routinely necessary 
  • Often used in evaluation for peripheral neuropathy
• Laboratory studies are indicated only when looking for additional pathology
  • Erythrocyte sedimentation rate and CRP → inflammatory conditions, infection
  • Rheumatologic evaluation (if appropriate)
  • CBC → leukocytosis may indicate infection
  • Troponin → myocardial ischemia

Comparison of diagnoses

The following table compares the clinical and diagnostic clues for some common musculoskeletal conditions manifesting with neck pain.

Management

Early management of neck pain focuses on proper initial evaluation, early return of motion, pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management, and judicious use of physical therapy.

Management after major trauma

• Backboard, rigid cervical collar
• Airway, breathing, and circulation (ABC) assessment
• Referral for immediate emergency care

Conservative measures

Conservative measures are usually used in patients without major trauma or red flag findings.

General treatment:

• Education and reassurance
• Postural improvements and modifications
• Avoidance of aggravating factors 
• Sleep position recommendations
• Heat or cold therapy (whichever relieves discomfort) for pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management

Physical and movement therapy:

• Home therapy exercises: 
  • ROM
  • Stretching
  • Postural
• Aerobic exercise (e.g., walking)
• Physical therapy: essential in the management of neck pain and avoidance of chronic neck pain
• Manual therapy or manipulation
• Consider mind–body exercises: 
  • Tai chi
  • Yoga

Pharmacologic measures

• Acetaminophen Acetaminophen Acetaminophen is an over-the-counter nonopioid analgesic and antipyretic medication and the most commonly used analgesic worldwide. Despite the widespread use of acetaminophen, its mechanism of action is not entirely understood. Acetaminophen 
• NSAIDs (caution in patients with gastric ulcer disease, heart disease, and renal disease)
• Muscle relaxants:
  • Controversial
  • Lack of quality evidence
  • Avoid long-term use
• Tramadol
  • Potential additive effect when used with acetaminophen
  • Avoid long-term use
• Duloxetine, gabapentin, or tricyclic antidepressants Tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications used in the management of mood disorders, primarily depression. These agents, named after their 3-ring chemical structure, act via reuptake inhibition of neurotransmitters (particularly norepinephrine and serotonin) in the brain. Tricyclic Antidepressants for patients for whom the above therapy fails.
• Systemic or epidural steroids 
  • May be considered in patients with radicular pain
  • Controversial
  • Lack of quality evidence
• Opiates are rarely indicated.

Interventional therapies

The following may be considered in association with pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management and/or physical medicine and rehabilitation:

• Acupuncture
• Dry needling
• Trigger-point injections
• Cervical medial branch blocks
• Percutaneous neurotomy

Surgical interventions

• Rarely indicated in nonradicular neck pain 
• Success rates higher for patients with radicular pain or myelopathic disease
• Early surgical referral is indicated for: 
  • Significant muscle weakness
  • Fractures
  • Myelopathy

Clinical Relevance

• Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis: cause of cervical spondylosis; due to cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage destruction and changes of the subchondral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones. Patients with osteoarthritis develop gradual joint pain, stiffness lasting < 30 minutes, and decreased ROM. Physical exam may reveal crepitus with joint motion. The diagnosis is clinical and supported with radiographic joint findings. Management includes conservative measures, analgesic medications, glucocorticoid intraarticular injections, and surgery for advanced disease.
• Herniated disc: prolapse of an intervertebral disc through the annulus fibrosus, which can lead to irritation and impingement on an adjacent nerve root and result in radiculopathy. Symptoms of herniated disc include pain, paresthesias, and weakness, depending on the severity of nerve involvement. Imaging will demonstrate disc protrusion. Management includes conservative measures, analgesics, physical therapy, and surgery for severe disease.
• Fibromyalgia Fibromyalgia Fibromyalgia is a chronic pain syndrome characterized by widespread body pain, chronic fatigue, mood disturbance, and cognitive disturbance. It also presents with other comorbid symptoms such as migraine headaches, depression, sleep disturbance, and irritable bowel syndrome. Fibromyalgia: nonarticular, noninflammatory disorder that causes chronic pain. Fibromyalgia Fibromyalgia Fibromyalgia is a chronic pain syndrome characterized by widespread body pain, chronic fatigue, mood disturbance, and cognitive disturbance. It also presents with other comorbid symptoms such as migraine headaches, depression, sleep disturbance, and irritable bowel syndrome. Fibromyalgia is poorly understood, but causes widespread muscle tenderness, including the neck. The diagnosis is clinical, and management focuses on stress relief, optimizing sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, mental health treatment, and nonopioid analgesics.
• Myofascial pain syndrome: muscle pain disorder that is similar to fibromyalgia. However, the pain in myofascial pain syndrome is typically localized to 1 anatomic region (such as the neck). The diagnosis is based on the presence of trigger points. Management can include physical therapy, massage, and nonopioid analgesics.
• Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis: autoimmune disease of the joints that causes an inflammatory and destructive arthritis. Atlantoaxial subluxation is common in rheumatoid arthritis and can cause neck and shoulder stiffness, radiculopathy, and myelopathy. Diagnosis is based on the clinical picture, inflammatory markers, rheumatoid factor (RF), and anti–cyclic citrullinated peptides (CCPs). Management starts with glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids, disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects. Disease-modifying Antirheumatic Drugs (DMARDs), and NSAIDs.
• Ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis (also known as Bechterew's disease or Marie-Strümpell disease) is a seronegative spondyloarthropathy characterized by chronic and indolent inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Ankylosing Spondylitis: seronegative spondyloarthropathy characterized by chronic and indolent inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Patients with ankylosing spondylitis will have progressive neck and low back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain (which improves with activity), morning stiffness, and decreased ROM of the spine. The diagnosis is based on the clinical history, physical exam, and imaging. Most patients are treated with physical therapy and NSAIDs.
• Giant cell arteritis Giant Cell Arteritis Giant cell arteritis (GCA), also known as temporal arteritis, is a type of large-vessel vasculitis that predominantly affects the aorta and its major branches, with a predilection for the branches of the carotid (including the temporal artery). Giant cell arteritis is defined by inflammatory leukocytes in the vessel walls leading to reactive damage, ischemia, and necrosis. Giant Cell Arteritis: large-vessel vasculitis that predominantly affects the aorta and its major branches, with a predilection for the branches of the carotid (including the temporal artery). Patients with giant cell arteritis can have headaches, neck pain, jaw pain, and vision problems. The diagnosis is made with temporal artery biopsy. Prompt treatment with glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids can relieve symptoms and prevent vision loss.
• Thoracic outlet syndrome Thoracic outlet syndrome Thoracic outlet syndrome (TOS) is a broad term used for a spectrum of syndromes related to the general region of the thoracic outlet, which involves the compression or irritation of elements of the brachial plexus, subclavian artery, or subclavian vein. Thoracic Outlet Syndrome: caused by the compression of the neurovascular structures at the thoracic outlet, especially those passing through the interscalene triangle. Signs and symptoms can include upper-extremity, shoulder, or neck pain and paresthesias. The diagnosis is made with clinical exam, imaging, and electrodiagnostic testing. Management generally includes physical therapy and analgesics.
• Epidural abscess: accumulation of pus in the epidural space. Patients with an epidural abscess may have back or neck pain (depending on the location) and fevers. Neurologic dysfunction can occur if the abscess compresses the spinal cord. MRI will confirm the diagnosis. Treatment includes antibiotics and aspiration of the abscess. Surgery is necessary in patients with neurologic dysfunction.