Neck pain one the most common complaints in general population and fourth leading cause of disability following low back pain, depression, and arthralgia. According to the duration of symptoms, it can be acute, sub-acute or chronic. Most important causes of neck pain are posture, cervical radiculopathy, myelopathy or degenerative diseases, trauma etc. Careful physical and clinical evaluation can be helpful in finding out the cause. Different clinical tests are available to differentiate between the aetiologies and among them, Spurling test is the most common test used. Mostly the treatment depends on the etiology. The treatment modalities adopted for neck pain are conservative therapy, pharmacological therapy, and surgical approach.
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Image: “neck check.” By woodleywonderworks. License: CC BY 2.0


Definition

Neck pain is defined as a sense of uncomfortable to the neck, which is considered one of the most neglected symptoms despite its physical, mental and even economic impact. It is one of the leading cause of DALY (disability-adjusted life year) loss or disability following other orthopedic causes like lower back pain and arthralgia. More 50 % of individual get some form of neck pain in their lifetime with a mean prevalence rate of the episode around 40 % per year. 

Classification of Acute Neck Pain

There is more than one way to classify neck pain e.g. according to chronicity (like acute vs chronic) of pain or according to the etiology (postural vs neuropathic). Since the duration of neck pain is the single most important predictor of outcome, classification according to the duration of symptom is most accepted one.

So, neck pain can be classified as

  • Acute: if the symptom persists for less than 6 weeks
  • Sub-acute: If the symptom persists for less than or equal to 3 months
  • Chronic: If the symptom persists for more than 3 months.

Sometimes this classification overlaps as chronic neck pain can present acutely or subacutely. So, all the causes of chronic or acute neck pain must be considered while treating a case of neck pain. 

Epidemiology of Acute Neck Pain

Incidence and prevalence are more in females compared to males. Mostly it affects the adult population and incidence increases with increase in age. Increased body mass index or obesity linked as risk factors for neck pain.

Several other risk factors identified are Occupation, sedentary lifestyle, previous history of trauma to the neck, smoking, depression, genetic predisposition (like Turner and down syndromes), concomitant lower back pain or rheumatic diseases etc.

Other associated co-morbidities are diabetes, headaches, arthralgia etc. Involvement in certain sports like hockey, wrestling, football need a special mention as an athlete has an increased risk of neck pain. An occupation like IT (information technology) professional with a long hour of sitting before computers, manual laborers, doctors or health care workers also has an increased risk. Poor ergonomics or workplace environment has also been identified as an important risk factor.

Causes of Acute Neck Pain

There have been a wide variety of causes of neck pain, that can be classified based on the nature of the disease, pathophysiology or site of the lesion. Here we are discussing the most commonly identified causes of neck pain:

  • Mechanical degeneration of vertebrae or ligament: mostly it affects the older people
  • Posture: Occupation related inappropriate posture and repetitive motion are the important cause in young population
  • Whiplash injuries: it is a major cause of acute neck pain in a quarter of patients with road traffic accidents.
  • Neck pain secondary to acute injuries like fall
  • Cervical canal stenosis: Mostly caused by degenerative disease leading to obliteration of neural foramina
  • Cervical radiculopathy: It generally involves the 7th and 8th cervical vertebrae/disc causing pain in neck and shoulder region.
  • Thoracic outlet syndrome: Due to mechanical compression of brachial plexus
  • Other conditions which are associated with the disease are rheumatic arthritis involving cervical region, osteomyelitis, arthritis, malignancies, fibromyalgia etc.

Clinical Features of Acute Neck Pain

Mostly pain is restricted to the posterior region but depending on the cause it can radiate to anterior side or shoulder girdle or forearm or arm or even to occiput. Generally, the pain intensifies with any passive or active movement and decreases with rest. The site of pain depends on the dermatome involved. The differently associated symptom may point out the cause of neck pain.

The following table shows the differently associated symptom and their causes.

Gait abnormalities, fatigability, restricted neck movement, high-grade spasticity, torticollis, clumsiness, sensory deficits, upper motor neuron signs

Aetiology Associated condition Associated symptom
Fractured vertebrae or ligament tear or spinal cord injury Road traffic accident or whiplash injury or fall from height Loss of consciousness, low score on Glasgow coma scale, cognitive derangement,

brain injuries like a subdural and epidural hematoma, headaches, neurologic signs and symptoms

Atlantoaxial subluxation Rheumatoid arthritis or congenital condition like down syndrome, arthropathy
Metastases due to malignancies Metastasis of Cancer of any organ to cervical vertebrae like prostate and breast cancer Anorexia, constitutional symptoms like weight loss, fever, myalgia, pain is diffuse, associated other joint pain, abnormal laboratory results, family history of carcinoma
Infectious diseases or systemic diseases Meningococcal Meningitis and other infectious agent presenting as meningitis, condition associated with substance abuse Typical features of meningitis like neck stiffness, fever, elevated white blood cell count, cerebrospinal fluid abnormality, photophobia
Abscess of neck region Epidural abscess Neck stiffness, high-grade fever, elevated white blood cell count, photophobia
Cervical canal stenosis Spinal cord compression or demyelinating disease Spasticity, rigidity, neurological signs like Hoffmann sign, Babinski sign positive, sexual dysfunction, urinary incontinence
Congenital abnormalities Spina bifida, Turner syndrome, down syndrome Genetical abnormality, skin tag, associated finding according to genetical abnormality
Cardiac causes Coronary artery pathology, myocardial ischemia, vertebral artery dissection Pain is radiated towards the arm and neck region is a typical finding in myocardial ischemia with associated severe chest pain, Sharp shooting pain in arterial dissection.

Physical Examination of Acute Neck Pain

Inspection

Careful inspection of patients posture on standing position can reveal important findings like cervical lordosis, kyphosis, scoliosis, head forward posture and torticollis.

Palpation

palpation of important landmarks like cervical spine, joint facets, sternocleid muscle, scalene muscle etc. may give important clues for diagnosis.

The range of motion

Since there is a restriction of movement in case of neck pain, careful evaluation of a range of motion mostly extension and flexion should be undertaken. Lateral bending and even rotatory movement to assess the symmetry of motion can reveal some pathological condition. Sometimes these motion test aggravates the pain.

Neurological examination

A complete and thorough neurological examination is a must for all cases of neck pain. Muscle power, reflexes, measuring the sensory factors like touch, pain temperature can also give the idea about dermatomal involvement.

Two most important causes of neck pain are Cervical radiculopathy and cervical myelopathy. These two conditions can be differentiated from each other by different tests.

Cervical radiculopathy 1.       Spurling test Rotation and lateral flexion of the neck causes pain on the affected side
2.       Shoulder abduction test Abduction of arm of the affected side causes radicular pain
3.       Neck distraction test Holding the occiput and the chin when examiner put axial traction to lift it then there is relief from the radicular pain
4.       Valsalva maneuverer Forceful expiration with mouth and nose closed causes pain relief
Cervical myelopathy 1.       Lhemitte sign Passive flexion of neck produces sharp electric sensation down the arm and spine.
2.       Hoffmann sign Flexion and adduction of index finger and thumb produces a sudden movement of distal phalanx of middle and fourth finger
3.       Babinski sign Stimulation of sole of the foot in a continuous manner produces dorsiflexion of fingers of the foot and in extensive disease, it may produce dorsiflexion and abduction of other toes
4.       Clonus Sudden dorsiflexion at wrist or ankle joint produces more than two repetitive movements at the specific joint
5.       Upper limb tension test Pain is accentuated by certain movements like shoulder abduction, depression of scapula, an extension of the wrist, external rotation of arm etc.

Another condition which poses a diagnostic dilemma for the physician is thoracic outlet syndrome. It is commonly mistaken for cervical radiculopathy.

Pain in thoracic outlet syndrome may be the arterial or venous origin and even it may be neurogenic. Neurogenic pain predominates compared to arterial/ venous pain.

Thoracic outlet syndrome the generally affects one side of the body, females are more prone to be affected, mostly occur in people after 40 years of age. Most of the cases have a history of trauma or repetitive stress.

Imaging modalities and even Doppler imaging technique are most helpful in evaluating pain of vascular origin but it has limited use in neurogenic pain.

Several tests can be used to differentiate between radiculopathy and thoracic outlet syndrome (presented in above table). There are specific tests for thoracic outlet syndrome also like Adson test, elevated arm stress test etc.

Investigations of Acute Neck Pain

Clinical examination of the neck is not enough to diagnose the definite cause of the acute neck pain because of the overlap in clinical manifestations between different diseases. Diagnostic imaging tests are considered a cornerstone in the diagnosis and management of a patient with neck pain.

X-ray

Radiography of the cervical spine can assist in determining the area of degenerative disease. Anteroposterior view, lateral views are most useful in delineating the lesion. Traumatic fracture and even congenital malformations can be ruled out through the odontoid view. Cervical canal stenosis or neural foramina obliteration and arthritic changes can be viewed best in oblique view. Most of the time x-ray may be normal patients with cervical region strain/ sprain. In degenerative diseases, the most common finding are the loss of disc space and osteophytes.

CT scan

Most important mode of investigation in bony abnormalities and fracture as it can delineate the bony structure of the neck revealing different types of neck diseases as TB affection or neoplastic metastasis of cervical vertebrae.

MRI

it is the best method to assess the cervical spine as the soft tissue like the spinal cord, nerve roots and disc can be visualized. MRI is the most important diagnostic modality for patients with motor neuron disease, cervical radiculopathy or myelopathy.

Treatment of Acute Neck Pain

Treatment of specific conditions

Acute neck pain cause is caused by a specific cause, as a fracture or inflammation, and in these situations, the aim after general conservative measures is to treat the diseases specifically either medically or surgically based on the severity of symptoms, indications, and complications of the disease.

Conservative therapy

Most of the cases with neck pain are treated with conservative therapy. Passive movement, muscle strengthening exercises some time found to provide immediate relief from the symptoms of neck pain. Such therapy mostly helpful in patients with neck pain originating from mechanical stress/ strain/ sprain.  Physical therapy in addition to home exercise and use of hard cervical collar can alleviate pain in most of the cases. It is sometimes called “wait and see” approach.

The alternative medicinal approach like spinal manipulation, chiropractic movement or manipulation can also provide short-term relief from symptoms.Conservative management must not be done in patients with trauma, malignancies, systemic infection, neurological findings, systemic inflammation etc.

Pharmacological therapy

  • NSAIDS are commonly used
  • Opioids can be used in severe cases of neck pain
  • Muscle relaxants (cyclobenzaprine in a dose of 5 to 10 mg three times daily per oral) may be useful in certain cases
  • Acute pain or radicular symptoms can be treated by different neuropathic medication like gabapentin in a dose of ranging from 300 to 1200 mg per oral thrice daily
  • A short course of oral steroids like prednisolone can be considered for pain
  • Injectable steroid can be used in cervical foramen or around facet joints

Surgical therapy

  • Surgery mostly depend on the condition or etiology
  • It is considered as the last resort
  • More than 80 percent of patient get some kind of benefit from surgical approach but careful evaluation of risk to benefit must be done before choosing this approach
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