Neck Pain

Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Musculoskeletal conditions can range in severity from simple strain to radiculopathy and myelopathy. A careful history and physical examination is essential in discovering the etiology and guiding therapy. Treatment of the majority of cases of neck pain is conservative and activity-based.

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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
  • 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, 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, Lyme disease)
  • Cervical spondylotic myelopathy 
    • Spinal cord dysfunction or injury
    • Causes are similar to those for cervical radiculopathy
  • Atlantoaxial subluxation or instability, which is usually associated with:
    • Rheumatoid arthritis
    • Down syndrome

Nonmusculoskeletal conditions:

  • Cardiovascular disease:
    • Angina
    • MI
  • Infection:
    • Meningitis
    • Epidural abscess
    • Discitis
    • Osteomyelitis
  • Neurologic:
    • Tension headaches
    • Chiari malformations
  • Rheumatologic disease:
    • Polymyalgia rheumatica
    • Rheumatoid arthritis
    • Ankylosing spondylitis
    • Fibromyalgia
    • Giant cell arteritis should be considered in a patient with: 
      • Neck pain
      • Headache
      • Jaw claudication
      • Associated visual changes
  • Malignancy: 
    • Metastatic disease
    • Apical lung tumor
  • Thoracic outlet syndrome (TOS)
  • Vertebral artery dissection
  • GI:
    • Biliary disease
    • Esophageal disease

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Clinical Presentation

Classification

Neck pain may be classified on the basis of the duration of symptoms:

  • Acute: symptoms persist for < 6 weeks
  • Subacute: symptoms persist for ≤ 3 months
  • Chronic: symptoms persist for > 3 months

History

  • Pain characteristics:
    • Onset and duration
    • Pain quality
    • Severity
    • Exacerbating and relieving factors
    • Radiation
  • Important associated symptoms:
    • Numbness
    • Paresthesia
    • Muscle weakness
    • Headache
  • Review of systems (examples, list is not exhaustive):
    • Fevers or chills → infection
    • Weight loss → malignancy
    • Vision changes → giant cell arteritis
    • Difficulty swallowing or pain with swallowing → esophageal disorders
    • Chest pain → angina or MI
    • Rash → herpes zoster
    • Bowel or bladder incontinence → spinal cord compression or myelopathy
  • Recent trauma
  • Past medical history 
    • Arthritis
    • Rheumatologic disease
    • Malignancy
    • Cardiovascular disease
    • Osteoporosis
    • Surgeries
    • Immunosuppression
    • IV drug use

Mnemonic

Important open-ended questions to ask when evaluating a patient with pain can be remembered with:

  • O: onset
  • P: provocation and palliation
  • Q: quality of the pain
  • R: radiation (or region)
  • S: severity
  • T: timing

Physical examination

Basic examination:

  • Observation: 
    • Posture and alignment
    • Deformities
    • Rash
  • Palpation of the neck: 
    • Tenderness
    • Muscular rigidity
    • Swelling
    • Asymmetry
    • Masses
  • Range of motion (ROM)
    • Rotation
    • Lateral bending
    • Forward flexion
    • Extension
  • Neurologic examination:
    • Dermatomal exam of upper extremities
    • Strength testing
    • Deep tendon reflexes (DTRs)
    • Gait

Special tests and signs:

  • Lhermitte’s sign: 
    • Test for cervical myelopathy
    • Passive or active flexion of the neck produces sharp, electric sensation down the arms or spine.
  • Hoffmann sign:
    • Upper motor neuron test (e.g., cervical myelopathy)
    • Sudden flexion of the middle finger elicits involuntary flexion of the thumb and index finger.
  • Spurling test (neck compression test):
    • Assesses for cervical radiculopathy by compressing the affected nerve root
    • Perform with care to avoid further injury.
    • Avoid performing in patients with Lhermitte’s sign
    • Procedure:
      • Patient’s neck is extended and rotated to one side
      • Downward force is applied to the top of the patient’s head
      • Radiation of pain to the ipsilateral upper extremity indicates a positive test

Red flag signs and symptoms

The following symptoms suggest serious pathology and should elicit an urgent evaluation:

  • Lower-extremity weakness
  • Gait disturbance
  • Bowel or bladder dysfunction
  • Fever
  • Unexplained weight loss
  • Positive Lhermitte’s sign

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 can evaluate for:
    • Degenerative changes
    • Disc height loss
    • Malalignment
    • Fractures
    • Cervical spine instability
  • CT:
    • Method of choice for fracture detection during trauma evaluations
    • Evaluation of bony anatomy and fractures
  • MRI to evaluate abnormalities of: 
    • Soft tissues
    • Intervertebral discs
    • 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.

Table: Comparison of diagnostic clues for common musculoskeletal conditions causing neck pain
ConditionClinical featuresDiagnosis
Cervical strain
  • Neck pain
  • Stiffness
  • Headaches
  • Tenderness on palpation of the neck and trapezius muscles
  • Provocative maneuvers for cervical radiculopathy are negative.
Clinical
Cervical spondylosis
  • Pain is primarily chronic and mechanical in nature.
  • Headaches
  • With or without neurologic symptoms
  • May be associated with cervical radiculopathy or myelopathy
  • Physical exam varies depending on severity of the degenerative process.
  • Clinical
  • Degenerative findings on imaging
Whiplash injury
  • Neck pain
  • Restricted motion
  • Occipital headaches
  • Less commonly associated with dizziness
  • Clinical
  • Imaging studies (if indicated) to rule out other pathology
Cervical radiculopathy
  • Radicular pain
  • Possible sensory and motor abnormalities
  • Positive Spurling test
  • Clinical
  • Imaging indicated for neurologic deficits:
    • Narrowing of the neural foramina
    • Nerve root compression
Cervical myelopathy
  • Progressive neck pain
  • Gait dysfunction
  • Extremity weakness
  • Vibratory/proprioception abnormalities
  • Bowel and bladder dysfunction
  • Upper motor neuron findings
  • Positive Lhermitte’s sign
MRI showing:
  • Cervical spinal cord compression
  • Changes in the spinal cord
  • Narrowing of the spinal canal

Management

Early management of neck pain focuses on proper initial evaluation, early return of motion, 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

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 
  • 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 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 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: cause of cervical spondylosis; due to cartilage destruction and changes of the subchondral bone. 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: nonarticular, noninflammatory disorder that causes chronic pain. Fibromyalgia is poorly understood, but causes widespread muscle tenderness, including the neck. The diagnosis is clinical, and management focuses on stress relief, optimizing 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: 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, disease-modifying antirheumatic drugs (DMARDs), and NSAIDs.
  • Ankylosing spondylitis: seronegative spondyloarthropathy characterized by chronic and indolent 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 (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: 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 can relieve symptoms and prevent vision loss.
  • 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.

References

  1. Isaac, Z., et al. (2021). Evaluation of the adult patient with neck pain. In Atlas, S.J., et al. (Ed.), UpToDate. Retrieved June 15, 2021, from https://www.uptodate.com/contents/evaluation-of-the-adult-patient-with-neck-pain
  2. Kaji, A. (2019). Evaluation and initial management of cervical spinal column injuries in adults. In Moreira, M.E. (Ed.), UpToDate. Retrieved June 15, 2021, from https://www.uptodate.com/contents/evaluation-and-initial-management-of-cervical-spinal-column-injuries-in-adults
  3. Robinson, J. et al. (2020). Clinical features and diagnosis of cervical radiculopathy. In Shefner, J.M. (Ed.), UpToDate. Retrieved June 15, 2021, from https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-cervical-radiculopathy
  4. Robinson, J. et al. (2021). Treatment and prognosis of cervical radiculopathy. In Shefner, J.M. (Ed.), UpToDate. Retrieved June 15, 2021, from https://www.uptodate.com/contents/treatment-and-prognosis-of-cervical-radiculopathy
  5. Levin, K. (2020). Cervical spondylotic myelopathy. In Aminoff, M.J. (Ed.), UpToDate. Retrieved June 15, 2021, from https://www.uptodate.com/contents/cervical-spondylotic-myelopathy
  6. Binder, A. (2005). Neck pain. American Family Physician 71:117–118. https://www.aafp.org/afp/2005/0101/p117.html
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  8. Teichtahl, A.J., McColl, G. (2013). An approach to neck pain for the family physician. Australian Family Physician 42:774–777. https://www.racgp.org.au/afp/2013/november/neck-pain/
  9. Moley, P.J. (2020). Evaluation of neck and back pain. MSD Manual Professional Version. Retrieved June 23, 2021, from https://www.msdmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/neck-and-back-pain/evaluation-of-neck-and-back-pain
  10. Freeman, M.D. (2021). Cervical sprain and strain. In Lorenzo, C.T. (Ed.), Medscape. Retrieved June 23, 2021, from https://emedicine.medscape.com/article/306176-overview

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