Written by Katherine Esser and Dr. Nabil Ebraheim
Neck pain is a common ailment of the American population, affecting 30 to 50% of adults annually1. While there are numerous etiologies of neck pain, this is a brief review of the more common causes and modes of treatment2.
Firstly, radiculopathy from disc herniation. In addition to neck pain, the patient will complain of arm pain that typically follows a myotomal pattern, and sensory symptoms (like burning and tingling) that follow a specific dermatome in the hand3. There may also be motor weakness of the upper extremity3. This is due to compression of a nerve root either by a disc herniation or by arthritis that narrows the foramen2. A neurological exam assessing motor, sensory and reflex testing should be done to determine cervical spine disc herniation. Treatment should first be non-surgical with anti-inflammatory medication, isometric exercises, physical therapy, and muscle relaxants2. An MRI should be ordered if symptoms do not improve after 6-12 weeks of conservative treatment. If there is an indication for surgery, it often involves decompression and fusion of the involved disc space. 26% of patients with cervical radiculopathy require surgery3.
Secondly, neck pain may be due to cervical myelopathy. This is the most common cause of non-traumatic spinal cord dysfunction4. It is due to direct compression of the spinal cord or surrounding blood vessels, and presents in a variety of ways clinically4. Indications of cervical myelopathy are an unstable and wide-based gait, clumsiness of the hands, occipital headaches, and discomfort of the neck2. The pain may not be severe, but insidious, gradual, and poorly characterized. An MRI may be ordered which will show compression of the spine2. Due to the slow, stepwise deterioration in cervical myelopathy, each stage may be treated differently4. There is conflicting evidence regarding the conservative versus surgical approach to treatment of cervical myelopathy. The goal for surgery is cord decompression with expansion of the spinal canal, restoration of cervical lordosis, and stabilisation if the risk of cervical kyphosis is high4. The evidence suggests mild cervical myelopathy should be treated conservatively with careful observation, whereas surgical intervention should be employed for moderate to severe cases4.
Thirdly, neck pain may be due to a whiplash injury. This is the most common traumatic cause of neck pain5. Specifically, neck hyperreflexia and neck pain after a car collision from behind. Pain may refer to the head, shoulder, or arm. There are usually no neurological deficits. The patient will have a soft tissue injury and an x-ray will show cervical lordosis due to muscle spasm. Treatment for a whiplash injury is aggressive physical therapy and mobilization.
Cervical spondylosis may also cause neck pain. This is arthritis of the spine. It is a natural degenerative process of cervical spine which will be shown on X-Ray. Degenerative changes start in the intervertebral discs with osteophyte formation and involvement of soft tissue structures. It is important to note many people over 30 years of age display similar abnormalities on imaging of the cervical spine and it may be difficult to delineate normal aging and disease. Cervical spondylosis can be diagnosed clinically based on characteristic exacerbation by neck movement. Although pain is focused in the cervical area, it is also referred to a wide area6. Cervical spondylosis should be managed medically and surgery should only be done if there is instability or neurological deficit3. In fact, there is evidence that suggests various exercise regiments may be more effective than usual medicinal care (analgesics, muscle relaxants) or stress management6.
While there are various
pathologies to include in the differential of neck pain, typically, patients
with neck pain will have no injury. Pain will be in the posterior neck, tender
to palpation with no radiation to the arm, no neurological deficits, and an
X-Ray will show mild arthritis. Often, patients will be prescribed
anti-inflammatory medication and referred to physical therapy.
References
1. Goode AP, Freburger J, Carey T. Prevalence, practice patterns, and evidence for chronic neck pain. Arthritis Care Res (Hoboken). 2010 Nov;62(11):1594-601. doi: 10.1002/acr.20270. Epub 2010 Jun 2. PMID: 20521306; PMCID: PMC2974793.
Ebraheim N. Neck pain causes and treatment - everything you need to know - Dr. Nabil Ebraheim [Internet]. YouTube. YouTube; 2021 [cited 2021Nov24]. Available from: https://www.youtube.com/watch?v=bwM5uskViJ4&ab_channel=nabilebraheim
3. Wong
JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors
of symptomatic cervical disc herniation with radiculopathy: a systematic review
of the literature. Spine J. 2014; 14(8):1781-9.
4. Bakhsheshian
J, Mehta VA, Liu JC. Current Diagnosis and Management of Cervical Spondylotic
Myelopathy. Global Spine J. 2017 Sep;7(6):572-586. doi:
10.1177/2192568217699208. Epub 2017 May 31. PMID: 28894688; PMCID: PMC5582708.
5. MacDermid
JC, Walton DM, Bobos P, Lomotan M, Carlesso L. A Qualitative Description of
Chronic Neck Pain has Implications for Outcome Assessment and Classification.
Open Orthop J. 2016 Dec 30;10:746-756. doi: 10.2174/1874325001610010746. PMID:
28217199; PMCID: PMC5301418.
6. Binder
AI. Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-31. doi:
10.1136/bmj.39127.608299.80. PMID: 17347239; PMCID: PMC1819511.
