What is Neck Pain?

Neck PainNeck pain is one of the most prevalent reasons individuals consult with their physician.

Neck pain occurs slightly more often in women, however many people experience some level of neck pain in the course of their lifetimes.

Most neck pain isn’t serious and may occur as a result of stress, improper body mechanics, like poor posture, or muscle strain in the neck from unusual or awkward positions.

Neck Pain, or cervicalgia, is a common and usually benign condition. The “cervical” spine, which is the Latin and medical term for neck, is made of seven cervical vertebra (C1-C7).

The neck bones (vertebrae) hold the intervertebral disc separating C2-C7, supporting soft tissue (muscles, ligaments, and tendons), and eight cervical nerves.  The neck supports the head, or cranium, which weighs roughly 15 pounds in an average adult, and is designed to allow significant flexion, extension, and rotation.  There are 14 pairs of muscles that help produce the complex movements of the neck.  Five joints, including the facet joints, provide a mobile connection between each vertebra from C2-C7.

Some serious symptoms that constitute a medical emergency that require immediate care include:

  • Loss of, or altered, consciousness
  • Changes in vision, such as blindness
  • Changes in bowel or urination
  • Nausea or vomiting
  • Fever
  • Weight Changes

The root cause or causes of neck pain have variable sources. Sudden pain lasting less than three months is classified as “acute.” Acute neck pain is commonly caused by facet syndrome (joint degeneration), muscle strain, or injuries, like whiplash. Pain lasting for more than three months, is classified as “chronic” neck pain. Neck pain can originate from multiple locations, but is often from facet joints irritation, discs, ligaments, and muscles.

Neck Anatomy

The cervical spine (neck) is complex and has many important functions, which include providing support and mobility to the head and neck, as well as protection of the spinal cord emerging from the brain. Understanding the anatomy of the spine is crucial for a correct diagnosis and creating an effective treatment plan to alleviate neck pain.

Bone structures

The cervical spine has seven small vertebrae (bones). The cervical spine starts at the base of the head/skull. The small vertebrae provide a support structure and protect the spinal cord. The vertebrae support the head/skull and allow for movement.

Vertebral Discs

In between each of the vertebrae are jelly-like discs that cushion and minimize impact to the cervical spinal column. The soft design of the discs creates a tendency to become herniated “collapse backwards” or bulge through or onto adjacent ligaments, nerves or the spinal column itself. It’s this irritation or inflammation that leads to neck pain.

Spinal Ligaments and Muscles

Ligaments and muscles are integral part of the spinal system. They attach to each vertebra, providing support, mobility and movement for the cervical spine. Spinal nerves are attached to the cervical spinal cord.

Ligaments and muscles innervate the skin, surrounding structures of the neck and upper extremities (arms and hands). Damage to these structures is one of the major sources of neck pain.

Atlas and Axis

The Atlas (first vertebrae) and Axis are the first two cervical vertebrae, starting at the base of the head. These two vertebrae form pivot-type joints to support the head, control head movement, and connect to the spine. They are also part of the body’s coordination and balance system. The cervical spine is the most flexible portion of the spinal cord, thus is the most vulnerable to injury or trauma.

The first through the third cervical nerves, exiting from the cervical vertebrae provide sensory information for the head and face.

If these nerves are compromised, compressed or inflamed, they cause neck pain and sensory issues in some head and face areas.

Greater and Lesser Occipital Nerves

If these nerves are comprised, this can cause radiating pain to the face and head. The other nerves lower in the cervical spine combine to form a large nerve group, which provides motor and sensory support to the upper extremities (arms). Symptoms may include:  weakness, pain, loss of feeling, or other issues in the arms.

Common Sources of Neck Pain

Head and Neck Pain

  • Muscle strain or tear.
  • Ligament strain or tear.
  • Myofascial syndrome is pain and inflammation from muscles and their connections.  It is often associated with trigger points.
  • Whiplash injury.
  • Spondylosis or wear and tear arthritis.
  • Disc related pain:  Discogenic pain, disc tears, bulging disc, herniated disc, disc protrusion, disc extrusion, and degenerative disc disease.
  • Radiculitis which is irritation of a cervical nerve root.
  • Radiculopathy which is an abnormality of a cervical nerve root.
  • Facet joint arthritis or facet syndrome.
  • Central spinal stenosis or narrowing of the spinal canal.
  • Neuroforaminal stenosis or narrowing of the nerve-exiting canal.
  • DISH Syndrome or Diffuse Idiopathic Skeletal Hyperostosis which is a syndrome with calcifications in the ligaments and tendons along the cervical spine
  • Vertebral body fracture

Axial neck pain describes a pattern of pain that is localized to the back of the neck region.  Most axial neck pain is self-limiting and resolves with appropriate conservative care.  A major study found that 79% of patients had pain relief with conservative treatment

Radicular neck pain, or radiating pain, is pain that typically radiates down one’s arm.  Radicular pain may also be a fairly benign course with 75% of patients having only one recurrence or mild symptoms with conservative treatment at nearly 20 years of follow-up

Even though the majority of neck pain is self-limiting, when neck pain is present in the following situations an individual should seek medical attention:

  • History of a recent infection
  • Fever or temperature over 100⁰ F
  • IV drug use, which increases risk of an infectious cause.
  • Neck pain worse at rest, which may be associated with an infectious cause or cancer.
  • Unexplained weight loss, which may be associated with cancer.

When the following conditions are present one should seek emergent care:

  • New or unexplained weakness or paralysis
  • Loss of Bowel or Bladder Control
  • New changes with prior history of cancer
  • Neck pain with shortness of breath
  • Neck pain with new dizziness or slurred speech
  • Recent significant trauma such as a fall from a height or motor vehicle accident

Statistics: Incidence/Prevalence of Neck Pain

The published prevalence of neck pain is 67% to 71%; that is, two-thirds of people have neck pain at some point in their life. Of these, about 10% of cases become chronic (3).  A Mayo Clinic study reported that “low back and neck pain is a common problem and one of enormous social, psychological, and economic burden” (4).  Expenses associated with neck pain, including medical and legal, are substantial.  Whiplash injury costs alone are an estimated $29 billion annually in the United States (5).  In 2005, a study found that Americans spent $85.9 billion looking for relief from back and neck pain.

Pathophysiology of Neck Pain

Neck PainNeck pain may come from soft tissues surrounding the spine, discs and joints between the vertebra, compression of the spinal cord or nerves, or referred pain. The pain may be the result of degenerative changes, autoimmune disorders, trauma, infection, or cancer.

Radiculopathy resulting from nerve root compression is usually caused by degenerative changes.  At the beginning stages of degeneration, the disc loses height and protrudes back into the spinal canal and foramen, which is the area where the nerves exit the spine.  The collapsing of the disc also causes the ligaments to fold into the canal and foramen.  Ultimately, the pressure that was once placed on the disc is shifted to the facet joints, resulting in the development of bone overgrowth or osteophytes, which lead to pressure on the nerve root or spinal cord.  Myelopathy, which is compression of the spinal cord, can be secondary to degenerative disease.  It can also be the result of a tumor, infection, or instability from systemic arthritides.  There is no intervertebral disc between the first two joints in the spine, the atlanto-occipital and atlantoaxial joints, and the area is often involved by destructive inflammatory arthritides, which may result in instability of the neck (7).  The facet joints are true joints, which makes them especially susceptible to degenerative changes and systemic arthritides.  Degenerative arthritis within the upper cervical spine can manifest as suboccipital headache (base of the skull) and localized pain, called cervicogenic headache.  This is thought to result from irritation of susceptible structures.

Inflammatory arthritis rarely causes isolated neck pain, but is associated with morning stiffness, rigidity, skin changes, and multiple joint involvement.  After the hands and feet, the cervical spine is the most common site of disease involvement in rheumatoid arthritis (8).   Ankylosing spondylitis often affects the entire skeletal spine with initial restriction of lumbar and chest motion and later involvement of the cervical spine.

The ligaments of the spine can become ossified (stiff), causing limited motion and contributing to the degenerative process.  They can also thicken over time, creating stenosis or narrowing in the spinal canal and compressing the spinal cord and exiting nerve roots.

Infections and neoplasms can destroy bone and can cause axial neck pain or radicular pain by irritating the nerves of the vertebra, and also may change the biomechanics of the facet joints and cervical disks.

Neck pain can commonly be referred from the shoulder, heart, lungs, viscera, or temporomandibular joint to the neck region since there is overlap of nerve distribution.  A large artery near the spine called the vertebral artery can begin to split, or dissect, and cause severe dizziness, slurred speech, and weakness. These symptoms are often associated with head position.

Causes of Neck (Cervical) Pain

  • Cervical myofascial pain causes tender areas of muscle that may be referred to as “knots” that are sensitive to touch, and can be the result of injury, stress, anxiety, or depression. These “knots” are sometimes called “trigger points” if pressure upon them “triggers” your typical pain.  Cervical muscle strain may also be caused by an injury or irritating daily activities, such as improper posture or poor sleeping position that leads to muscle spasms. The pain is commonly associated with stiffness and tightness in the upper back or shoulder.
  • Cervical spondylosis is the result of abnormal wear and tear, which causes gradual narrowing of the disc space and deformed bone growth, called bone spurs.  This combination leads to increased pressure on surrounding tissue and nerves. This can cause pain, and possible weakness, numbness in the arms or shoulders, and even headaches. Cervical facet syndrome is frequently associated with the degenerative changes of cervical spondylosis and is commonly caused by repeated backwards extension of the neck and is the most common location of whiplash injury.  Pain is most often felt in the middle or side of the neck, in the shoulders or at the base of the head.
  • Whiplash injury (cervical hyperextension injury) is commonly caused by motor vehicle accidents through a rapid forward/backward mechanism of the cervical spine.  Patients usually report severe pain, muscle spasm, and loss of range of motion in the neck. The facet joints are usually involved, as well as the surrounding tissues.
  • Discogenic pain is caused by degenerative changes, disc tears, bulging disc, herniated disc, disc protrusion, disc extrusion, and/or degenerative disc disease within the cervical intervertebral discs.  Pain occurs in the neck when turning the head, and may escalate when the neck is set in single position for an extended period of time.  Muscle tightness/spasms or pain radiating into the arms may also be experienced.  
  • Cervical radiculopathy is caused by arthritis, a herniated disc, or a mass that presses against and irritates an adjacent nerve root.  Signs of radiculopathy can include pain, weakness, or changes in sensation in the arms.
  • Cervical central stenosis is a narrowing of the spinal canal usually caused by a herniated disc, thickening of ligaments, overgrowth of the facet joints, spondylosis, tumor, or infection. The primary symptoms are chronic pain and numbness, but may result in lower extremity weakness and gait disturbance. The most serious complication is mylopathy, which occurs after damage to the spinal cord.
  • Cervical neuroforaminal stenosis is the narrowing of foraminal spaces (where the nerves exit the spinal canal) between the vertebra typically caused by herniated discs or bone spurs.  This narrowing creates pressure or causes irritation on the nerve roots, leading to nerve pain, weakness, and numbness.
  • Cervical spondylotic myelopathy results from degenerative changes that narrow the central spinal canal causing pain, weakness, difficulty walking, bowel or bladder dysfuntion, and sexual dysfunction.
    • Myelopathy is defined as damage to the spinal cord.  When myelopathy relates to trauma it is called a spinal cord injury.  When myelopathy relates to inflammation it is called a myelitis.  When myelopathy is due is a vascular insult it is known as a vascular myelopathy.
  • Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a syndrome of calcification or hardening of the ligaments and tendons of the cervical spine.  A minority of patients suffer from stiffness, loss of mobility, and pain.

Risk Factors

  • Age of 50 years or greater
  • History of injury
  • Deformities, arthritis, and narrowing of the spine
  • Stress
  • Depression
  • Poor posture
  • Heavy physical work
  • Smoking
  • Drug abuse
  • Poor physical condition
  • Lack of exercise.

Diagnosis

Diagnosis of neck pain is most often done by a medical physician. The physician performs a medical history and physical examine over certain areas of the spine; as well as performing various muscle tests to find any limitations in movement in the upper extremities.

The physician most likely will order one or more visual tests; such as X-ray, Computerized Magnetic resonance imaging (MRI) or Bone scan. MRI’s are considered the standard of care to detect the cause or causes acute or chronic neck pain.

Physical Exam findings test

A physician will observe the patient’s general gait and posture.  In addition the physician will palpate or feel the spine, surrounding tissue, and joints.  Finally, neurologic signs including range of motion, muscle strength, reflexes, and sensory signs are assessed. Tenderness in the middle of the spine is more likely ligament injury as opposed to tenderness to either side of the spine (10).  Myofascial pain is likely to worsen with neck flexion, whereas discogenic neck pain is more commonly exacerbated by neck extension or rotation.  Typically, arthritis within the atlanto-occipital joints is worsened with extreme neck flexion and extension, whereas atlantoaxial arthritis is worsened with rotation.  Range of motion in the cervical spine progressively decreases with age, even in healthy individuals.  Changes in muscle strength and sensation vary with the amount of compression on the nerve root.  This may be a grossly visible deficit or more subtle, necessitating further testing.

Imaging for neck pain

Together with a thorough history and examination, imaging studies may prove to be critical in formulating a differential diagnosis and identifying the correct pain generator.  Imaging modalities that may be useful in diagnosing neck pain include cervical radiographs (x-ray), computed tomography (CT scans), and magnetic resonance imaging (MRI).  Normal patients without any neck pain may show degenerative signs by the age of 60 (11).  X-rays should not be obtained until four weeks of conservative treatment have failed, unless the patient presents with trauma, symptoms of infection/cancer, or worsening neurologic deficits (12).  MRI is indicated for progressive neurologic loss, disabling weakness, and is recommended for patients with neck pain after 6 weeks of conservative care. CT myelography should not be used as the initial test unless MRI is contraindicated, as MRI is better for seeing spinal cord lesions and pathology (12, 13).  MRI results must be used in correlation with physical examination since normal patients have been found to have abnormal cervical spine MRI (14).

Neurophysiologic procedures are needed when the exam and imaging studies do not match.  Electromyography, nerve conduction studies, and somatosensory evoked responses help to decipher between spine and peripheral problems as well as nerve root problems from a radiculopathy.

Diagnostic Interventions for neck pain

  • Selective Nerve Root Blocks are a local injection procedure used for diagnostic and therapeutic purposes of neck pain.  It has also been used when the clinical exam and imaging studies fail to correlate.
  • Medial Branch Blocks (MBBs) may be therapeutic and/or diagnostic.   If there is no neck pain relief after a MBB, then the neck pain is likely not coming from the facet joint.  If the pain gets >50% better for a few hours, the neck pain may be caused by the facet joints.
  • Discography is used to determine whether or not the neck pain is coming from a disc and for identifying abnormalities in the disc.
    • Abnormalities can include disc herniations, tears and fissures.  This procedure involves the injection of contrast dye into the center of a disc under x-ray guidance. It is strictly a diagnostic procedure.
  • Trigger Point Injections (TPIs) can diagnose if muscles are the source of neck pain.
  • Hardware Injections can diagnosis if hardware implanted in the neck is a source of neck pain.

Treatments for Neck Pain

Medication Treatment Options, by Classs

  • Non Steroidal Anti-Inflammatory Drugs (NSAIDs) for Neck Pain Treatment: Ibuprofen, Advil ®, Aleve®, Nuprin®, Motrin® and others are anti-inflammatory medications.  These medications provide good short-term relief of neck pain and can be used as an adjunct for long-term pain conditions. Because of the risk of ulcers, gastrointestinal bleeding, and decreased kidney function talk with your doctor before using these medications.
  • Acetaminophen (Tylenol®) for Neck Pain Treatment: has been shown to be as effective as ibuprofen in relieving pain.   This medication is often added to other pain medications because of its synergistic effect with these medications.  This medication must be taken as directed and care should be taken when taken regularly, as excessive use can cause liver dysfunction.
  • Muscle relaxants for Neck Pain Treatment: including cyclobenzaprine (Flexeril), metaxalone (Skelaxin®), methocarbamol (Robaxin), tizanadine (Zanaflex), baclofen (Lioresal), and carisoprodol (Soma) treat painful muscle spasms.  The most common side-effects include drowsiness, dizziness, drug interactions, and abuse (most commonly with Soma).
  • Anti-Convulsants for Neck Pain Treatment:  are also considered membrane stabilizing medications as they are believed to “calm down irritated or hyperexcited nerves” which are responsible for neuropathic pain.  These medications include gabapentin (Neurontin), pregabalin (Lyrica®), topiramate (Topamax), and others.  Many have the side-effect of weight gain (excluding topiramate), drowsiness, dizziness, and trouble concentrating.
  • Anti-Depressants for Neck Pain Treatment:  are also considered membrane stabilizing medications as they are believed to “calm down irritated or hyperexcited nerves” which are responsible for neuropathic pain.  Within these medications are multiple tricyclic anti-depressant (TCAs) medications, which include the commonly used pain medications amitryptiline (Elavil) and nortriptyline (Pamelor).  Newer anti-depressant pain medications are in the serotonin norepinephrine reuptake inhibitor(SNRI) category.  These medications include duloxetine (Cymbalta®) and milnacipran (Savella®).
  • Steroid medications for Neck Pain Treatment:  A high-dose, fast-taper course of corticosteroids (ie. Medrol dose pack) can be used if there is a strong suspicion of nerve root impingement by disk protrusion or spondylosis.
  • Opioid medications for Neck Pain Treatment:  are also called narcotic pain relievers.  These include codeine, hydrocodone, morphine, oxycodone, oxymorphone, hydromorphone, meperidine, fentanyl, methadone, propoxyphene and other medications.  These medications are used to treat severe pain.  Side-effects commonly include nausea, drowsiness, dizziness, tolerance, constipation, and addiction.

Minimally Invasive Interventions for Neck Pain Treatment

  • Epidural Steroid Injections (ESIs) for Neck Pain Treatment are commonly used to treat radicular pain symptoms or pain which radiates from an irritated nerve root. Often the goal of ESIs is to allow sufficient pain relief to permit more active physical therapy and greater functional recovery.  The procedure involves injecting a corticosteroid under x-ray guidance into the epidural space, which is the space around the spinal cord.  The steroids act on the nerve roots as they branch from the spinal cord by decreasing inflammation and irritation.  In a recent 2009 study, transforaminal epidural steroid injections (TFESIs) were effective in treating cervical radiculopathy in 76.1% of patients at a short-term follow-up (15).
  • Lysis of Adhesions (adhesiolysis) for Neck Pain Treatment is also known as the “Racz procedure” because it was invented by Dr. Gabor Racz.  The procedure is similar to an epidural steroid injection, but is designed to dissolve scar tissue in the epidural space.  It is used to treat post-laminectomy syndrome, radiculopathy, spinal stenosis, and disc disease.
  • Medial Branch Blocks (MBBs) for Neck Pain Treatmentor facet injections and are used to treat neck pain that comes from the facet joints. The “blocks” work by blocking the nerves that innervate the facet joints, which are prone to arthritic changes.  In a recent study it was noted that “significant pain relief, and functional status improvement was seen in patients treated with MBBs” (16).
  • Radiofrequency Ablation (RFA) for Neck Pain Treatment is a procedure that targets the same medial branch nerves, and thus, has similar indications to MBBs.  Radiofrequency ablation uses electrical energy to cauterize or “burn” the nerves that innervate the joints.  RFA blocks the ability of the facet joints to send painful signals to the brain.
  • Spinal Cord Stimulation (SCS)for Neck Pain Treatment, known as the “pacemaker for pain” is a minimally invasive procedure that involves implanting a device that applies low currents of electrical stimulation through thin wires.  The leads or wires are placed under x-ray guidance into the epidural space, where they block pain signals.  A 2007 study reported patients experienced a significant (70-90%) reduction in neck and upper extremity pain from cervical SCS following unsuccessful cervical spine fusion surgery (17).
  • Trigger Point Injections (TPIs) for Neck Pain Treatment can be an effective treatment for muscle spasms. The procedure involves injecting a local anesthetic and/or steroid into a hyperirritable area of muscle, called a trigger point.
  • Botox Injections for Neck Pain Treatmentwas found to be “safe and efficacious for the management of patients with type A-resistant cervical dystonia” in 1999 (18).  Along with dystonia, Botox has been found to be effective in patients with whiplash injuries.  Patients experienced improved range of motion in addition to pain relief (19).  The procedure involves an injection of a small dose of botulinum toxin into spastic muscles.

Surgical Interventions for Neck Pain

Cervical myelopathy with very mild neurological deficits can be followed closely. Unfortunately, the typical disease progresses with extended periods of stability with episodes of deterioration.  Definitive indications for surgery include presence of weakness, progression of neurological signs or symptoms, difficulty walking, or change in bowel or bladder function.

Typically, surgeons use two surgical techniques for cervical spine surgery:

Spinal Decompression for Neck Pain Treatment, in which pressure on the spinal cord or spinal nerve roots is reduced by:

  • Discectomy – Removing part or all of an intervertebral disc
  • Laminectomy – Removing part of the spinal bone
  • Foraminotomy – Removing bone and/or disc that encroach upon a nerve foramen
  • Corpectomy – Removing an entire vertebra

Spinal Stabilization for Neck Pain Tretment, in which the surgery limits motion between vertebrae:

  • Disc Replacement – artificial cervical disc replacement involves implanting a disc after a discectomy is performed.
  • Spinal Fusion – involves joining selected bones in the neck together using a bone graft, screws, rods and plates.

Complementary and Alternative Treatment Options for Neck Pain 

  • Physical Therapy for Neck Pain Treatmentis beneficial in both rehabilitation from an injury and prevention of future injury. Passive physical therapy involves: heat/ice packs, TENS, ultrasound.  Active physical therapy includes: stretching, strengthening exercises, spinal manipulation, and low-impact aerobic conditioning.  One study reported that patients suffering from mechanical neck pain experienced a 62% perceived treatment success with manual physical therapy (20).
  • Chiropractic Manipulations for Neck Pain Treatment that are done correctly as targeted adjustments may significantly reduce neck pain when combined with other modalities of treatment. A recent study found that two-thirds of patients report “recovery” from neck pain with chiropractic care and concluded  that “the benefits of chiropractic care for neck pain seem to outweigh the potential risks” (21).
  • Exercise for Neck Pain Treatment works similar to physical therapy by increasing strength, and also releases endorphins.  A 2001 study found that exercise is “more beneficial to patients with chronic neck pain than the use of spinal manipulation alone” (22).
  • Proper Nutrition for Neck Pain Treatmentcan prevent nutritional deficits, which may otherwise lead to accelerated degenerative disease. A diet rich in Omega-3 fatty acids has been recommended for many purposes, but pain relief hasn’t been one of those until recently. Research has suggested that omega-3 is an “attractive adjunctive treatment for joint pain associated with rheumatoid arthritis, inflammatory bowel disease, and dysmenorrhea” (23).  A great way to increase omega-3 consumption is to add ground flax seed to daily meals.
  • Acupuncture for Neck Pain Treatment involves placing small needles into the skin, causing release of hormones called “endorphins“, the body’s natural pain reliever.  Acupuncture has been used for several thousand years to treat pain and other maladies and has  been shown to be very helpful at relieving symptoms in those with chronic pain (24).
  • Biofeedback for Neck Pain Treatment is a treatment that teaches a patient to become aware of his/her body processes that are normally thought to be involuntary, such as temperature regulation, heart rate, and muscle tension.  A better awareness of one’s body teaches one to effectively relax and can help to relieve pain.
  • Transcutaneous Electrical Nerve Stimulation (TENS) for Neck Pain Treatment is a technique that relieves pain by applying mild electric current to the skin at the site of the pain.
  • Massage for Neck Pain Treatment of the tender areas may help relieve muscle spasms or contractions and provide pain relief.
  • Yoga  Neck Pain Treatmentis a program of exercises to help improve flexibility.  Yoga leads to a decrease in stress and maintains health. The basic components of yoga are proper breathing, stretching, and posture.
  • Prolotherapy Neck Pain Treatment, also known as Regenerative Injection Therapy, is a technique of injecting irritant solution into the painful areas of the body.  The irritant causes a local inflammatory reaction and one’s body regenerates or heals the pain generating tissue.  Prolotherapy is generally used in pain causing tendons and/or ligaments with the aim of strengthening weakened connective tissue and alleviating pain.
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References

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