Table of Contents
Neck pain is defined as an uncomfortable feeling in the neck, a symptom that is often neglected despite its physical, mental, and even economic impact. It is 1 of the leading causes of DALY (disability-adjusted life year) loss or disability after other orthopedic causes such as lower back pain and arthralgia. More than 50% of the general population experiences some kind of neck pain in their lifetime, with a mean prevalence rate of 1 episode of neck pain in approximately 40% of the population per year.
There are a number of ways to classify neck pain, depending on chronicity (acute vs. chronic) or etiology (postural vs. neuropathic). Since the duration of neck pain is the single most important predictor of outcome, classification according to duration is the most accepted classification in clinical practice.
Neck pain can be classified as:
- Acute: if symptoms persist for less than 6 weeks
- Sub-acute: if symptoms persist for 3 months or less
- Chronic: if symptoms persist for more than 3 months
Patients with chronic neck pain may also present with superimposed acute or subacute neck pain.
Acute neck pain is more common in women than in men, and in adults than children. 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 include occupation, sedentary lifestyle, previous history of trauma to the neck, smoking, depression, genetic predisposition (Turner and Down syndromes), concomitant lower back pain, or rheumatic diseases.
The most common causes of neck pain include 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 2 important causes of neck pain in young adults.
- Whiplash injuries: a major cause of acute neck pain in a quarter of patients with road traffic accidents
- Acute injuries: such as falls
- Cervical canal stenosis: mostly caused by degenerative disease leading to obliteration of the neural foramina
- Cervical radiculopathy: generally involves the 7th and 8th cervical vertebrae/disc, causing pain in the neck and shoulder region
- Thoracic outlet syndrome: due to mechanical compression of the brachial plexus
- Rheumatoid arthritis: involving the cervical region, osteomyelitis, malignancies, and fibromyalgia
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 occiput. Generally, pain intensifies with any passive or active movement and decreases with rest. The different characteristics of the pain can help narrow down the differential diagnosis.
The table below outlines important clues from the patient history that can help the practitioner uncover 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 a height||Loss of consciousness, a low score on the Glasgow coma scale, cognitive derangement, brain injuries such as a subdural or an epidural hematoma, headaches, neurologic signs and symptoms|
|Atlantoaxial subluxation||Rheumatoid arthritis or congenital conditions such as Down syndrome||Gait abnormalities, fatigability, restricted neck movement, high-grade spasticity, torticollis, clumsiness, sensory deficits, upper motor neuron signs|
Careful inspection of the patient’s posture while in the standing position can reveal important findings such as cervical lordosis, kyphosis, scoliosis, head-forward posture, and torticollis.
Palpation of important areas such as the cervical spine, joint facets, sternocleidomastoid muscle, and scalene muscle may give important clues to the most likely diagnosis.
Range of Motion
Since there is a restriction of movement in patients with neck pain, careful evaluation of the 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, however, motion tests can aggravate the pain.
A complete and thorough neurological examination is a must for all cases of neck pain. Muscle power, reflexes, and measuring sensory factors such as touch, pain, and temperature can also give clues to dermatomal involvement.
The 2 most important causes of neck pain are cervical radiculopathy and cervical myelopathy. These 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 the arm of the affected side causes radicular pain.|
|3. Neck distraction test||Holding the occiput and the chin when the examiner uses axial traction to lift it gives relief from the radicular pain.|
|4. Valsalva maneuver||Forceful expiration with mouth and nose closed causes pain relief.|
|Cervical myelopathy||1. Lhemitte sign||Passive flexion of the neck produces a sharp electric sensation down the arm and spine.|
|2. Hoffmann sign||Flexion and adduction of the index finger and thumb produce a sudden movement of distal phalanx of the middle and 4th fingers.|
|3. Babinski sign||Stimulation of the sole of the foot in a continuous manner produces dorsiflexion of fingers of the foot and, in extensive disease, may produce dorsiflexion and abduction of other toes.|
|4. Clonus||Sudden dorsiflexion at wrist or ankle joint produces more than 2 repetitive movements at the specific joint.|
|5. Upper limb tension test||Pain is accentuated by certain movements such as shoulder abduction, depression of scapula, extension of the wrist, external rotation of the arm, etc.|
Another condition that poses a diagnostic dilemma for the physician is thoracic outlet syndrome, as it is commonly mistaken for cervical radiculopathy. Thoracic outlet syndrome usually affects 1 side of the body. Women are more prone to be affected as are patients older than 40 years of age. Most patients have a history of trauma or repetitive stress.
Imaging modalities and, sometimes, the Doppler imaging technique, can also help evaluate pain that is vascular in origin, but they have limited use in evaluating neurogenic pain.
Several tests can be used to differentiate between cervical radiculopathy and thoracic outlet syndrome (see table below). There are also specific tests for thoracic outlet syndrome, including the Adson test and the elevated-arm stress test.
Clinical examination of the neck is not enough to diagnose the definitive cause of 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.
Radiography of the cervical spine can assist in determining the area of degenerative disease. Anteroposterior view and lateral views can be used to delineate 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 are best viewed in oblique view. In degenerative diseases, the most common findings are a loss of disc space and osteophytes.
Computed Tomography (CT) Scan of the Cervical Region
A CT scan is the most important mode of investigation in bony abnormalities and fractures 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)
Magnetic resonance imaging is the best method to assess the cervical spine, as soft tissue such as the spinal cord, nerve roots, and disc can be visualized. Magnetic resonance imaging is the most important diagnostic modality for patients with motor neuron disease, cervical radiculopathy, or myelopathy.
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.
Most cases of neck pain are treated with conservative therapy. Muscle-strengthening exercises have been found to provide some relief from the symptoms of neck pain. This therapy is most helpful in patients with neck pain originating from mechanical causes such as strain. Physical therapy, in addition to home exercise and the use of a hard cervical collar, can alleviate pain in most patients.
Alternative medicinal approaches such as spinal manipulation or chiropractic movement or manipulation can also provide short-term relief from symptoms. Conservative management should not be offered to patients with trauma, malignancies, systemic infection, neurological findings, or systemic inflammation, however.
- Non-steroidal anti-inflammatory drugs are commonly used.
- Opioids can be used in severe cases of neck pain (note that opioids can cause dependence).
- Muscle relaxants (cyclobenzaprine in an oral dose of 5–10 mg 3 times daily) may be useful in certain cases.
- Acute pain or radicular symptoms can be treated by different neuropathic medications such as gabapentin in a dose ranging from 300–1,200 mg 3 times a day.
- A short course of oral steroids such as prednisolone can be considered for pain caused by an inflammatory condition.
- An injectable steroid can be used in the cervical foramen or around facet joints.
- The decision to use surgery mostly depends on the condition or etiology; however, it is considered to be the last resort.
- More than 80% of patients receive some kind of benefit from the surgical approach, but a careful evaluation of the risk-to-benefit ratio must be done before choosing this approach.