Neck pain is one of the most common complaints in the general population and the fourth leading cause of disability following low back pain, depression, and arthralgia. According to the duration of the symptoms; it can be acute, sub-acute or chronic. The most common causes of neck pain are posture-related, cervical radiculopathy, myelopathy, degenerative diseases, or trauma. Careful physical and clinical evaluation can be helpful in finding out the cause. Computed tomography is superior to any other imaging modality for the evaluation of the bony structure of the cervical spine, whereas, magnetic resonance imaging studies might be helpful in the exclusion of a soft-tissue disease process such as myelopathy. Treatment of neck pain is usually conservative. Patients who do not respond to medical therapy might benefit from a surgical intervention. 
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Image: “neck check.” By woodleywonderworks. License: CC BY 2.0


Definition

Neck pain is defined as a sense of uncomfortableness to the neck, which is often neglected despite its physical, mental and even economic impact. It is one of the leading causes of DALY (disability-adjusted life year) loss or disability following other orthopedic causes like lower back pain and arthralgia. More than 50% of general population get some sort of neck pain in their lifetime with a mean prevalence rate of one episode of neck pain 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) 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 pain is the most accepted one in clinical practice.

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.

Patients with chronic neck pain might present with superimposed acute or subacute neck pain.

Epidemiology of Acute Neck Pain

Acute neck pain is more common in females than in males. It most commonly affects adults and there is a positive correlation between age and the incidence of neck pain. Increased body mass index and obesity are also associated with 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.

Causes of Acute Neck Pain

The most common causes of neck pain can be summarized in the following:

  • Mechanical degeneration of the vertebrae or ligaments: this is more common in the elderly.
  • Posture: occupation related inappropriate posture and repetitive motion are two important causes of neck pain in the 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 falls.
  • 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
  • Rheumatoid arthritis involving the cervical region, osteomyelitis, malignancies, and fibromyalgia can also cause neck pain.

Clinical Features of Acute Neck Pain

In most cases of neck pain, the pain is restricted to the posterior region of the neck. Radiation to the anterior side of the neck or the shoulder is dependent on the cause. Pain can also radiate to the forearm, arm, or the occiput. Generally, the pain intensifies with any passive or active movement and decreases with rest. The different characteristics of the pain can help in narrowing down the differential diagnosis. The following table shows some important clues from the history that one can use to figure out the most likely cause of neck pain in the patient.

Etiology Clues from the history Associated symptoms
Fractured vertebrae, ligament tear or spinal cord injury Road traffic accident, whiplash injury, or fall from height

Loss of consciousness, low score on Glasgow coma scale, cognitive derangement, brain injuries like a subdural or an epidural hematoma, headaches, neurologic signs and symptoms

Atlantoaxial subluxation Rheumatoid arthritis or congenital conditions like down syndrome Gait abnormalities, fatigability, restricted neck movement, high-grade spasticity, torticollis, clumsiness, sensory deficits, upper motor neuron signs
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 Genetic or syndromic features
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 the patient’s 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, sternocleidomastoid muscle, and scalene muscle may give important clues for the most likely 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 a 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 an 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.

Thoracic outlet syndrome usually affects one side of the body. Females are more prone to be affected. It occurs in people older than 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, and lateral views are most useful in delineating the lesion. Traumatic fracture and 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. In degenerative diseases, the most common findings are the loss of disc space and osteophytes.

Computed Tomography (CT) scan of the cervical region

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 tuberculosis infection or neoplastic metastasis to the cervical vertebrae.

Magnetic Resonance Imaging (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

While conservative therapy aims to minimize neck pain, specific treatment is usually indicated if the etiology of the pain can be determined.

Conservative therapy

Most of the cases with neck pain are treated with conservative therapy. Muscle strengthening exercises were found to provide some relief from the symptoms of neck pain. Such therapy is mostly helpful in patients with neck pain originating from mechanical causes such as a strain.  Physical therapy in addition to home exercise and use of hard cervical collar can alleviate pain in most of the cases.

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

Pharmacological therapy

  • Nonsteroidal anti-inflammatory drugs are commonly used
  • Opioids can be used in severe cases of neck pain. Opioids can cause dependence
  • 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 medications like gabapentin in a dose of ranging from 300 to 1200 mg three times a day.
  • A short course of oral steroids like prednisolone can be considered for pain caused by an inflammatory condition
  • 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 ratio must be done before choosing this approach
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