Neck Pain

Neck pain is not as prevalent as back pain when reviewing the medical literature primarily because it is often included under the heading of “back pain”.  Neck pain is also difficult to differentiate from shoulder pain as the two conditions often overlap one another.  Nevertheless, neck pain does represent a common reason people visit their doctor and will be reviewed here.

There are many causes of neck pain many of which overlap one another. Below is a brief overview of some of the most common causes of neck pain.

Spondylosis
Most neck problems are the result of degenerative changes in the joints of the neck that happen over the course of years. Over time these degenerative changes, known as spondylosis, will result in pain. An important note is that most problems associated with spondylosis are a normal part of aging.

Degenerative Disc Disease
The normal aging process also involves changes within the intervertebral discs. Repeated stresses and strains weaken the connective tissues that make up a disc. Over time, the disc loses its ability to absorb shock resulting in an even greater toll on the disc and other structures of the neck.

As disc degeneration progresses, the space between the vertebrae becomes smaller. This compresses the spinal joints, eventually resulting in the development of arthritis in the spinal joints.

These degenerative changes in the disc cause the spinal segment to become loose and unstable resulting in even greater wear and tear and eventually leading to disc herniation and protrusion.  A herniated disc in the neck is often associated with a pinched nerve and subsequent upper extremity pain and weakness. 

Further disc degeneration results in the development of bone spurs, which is the spine’s attempt to stabilize itself. These bone spurs can further irritate the nerves exiting the neck and causing pain, numbness, and weakness in the neck, arms, and hands.

Muscle Strain and Whiplash
People with minor neck pain or stiffness are often told they have a muscle strain when, in fact, there is very little muscle involvement other than protective muscle guarding or spasm which is the body’s way of protecting itself from further injury.

A true muscle strain is a condition where the muscle has been involuntarily overstretched.  A classic example of this type of muscle strain is the whiplash syndrome.  Whiplash was first described in 1923 and was defined as an acceleration-deceleration injury to the neck.  Recent definition of whiplash, however, includes all types of neck injuries associated with motor vehicle accidents.  Whiplash is graded on a 0 – IV scale with a Grade 0 representing no pain and no physical signs and a Grade IV representing pain complaints along with fracture and/or dislocation.

Mechanical Neck Pain
Mechanical neck pain is caused by the general wear and tear of the various parts of the neck and is likened to a machine that begins to wear out. Mechanical pain usually starts from degenerative changes in the disc and subsequent irritation of the spinal joints. The pain is usually chronic and is typically felt in the neck, head, upper back, or into the shoulder. Mechanical neck pain usually doesn’t cause weakness or numbness in the arm or hand, because the problem is not from pressure on the spinal nerves.

Cervical Instability
Cervical instability means there is excessive movement in bones of the cervical spine. Instability in the cervical spine is the result of tearing or excessive stretching of the ligaments that support the neck.  Cervical instability is usually the consequence of a severe injury to the head or neck, but people with diseases that loosen their connective tissue (such as rheumatoid arthritis or Down’s Syndrome) may also have spinal instability.  Instability in the upper cervical spine is especially dangerous as it can create vertebral movement into the spinal cord.

Spinal Stenosis (Cervical Myelopathy)
Spinal stenosis of the cervical spine refers to a narrowing of the spinal canal where the spinal cord can become compressed.  Spinal stenosis may be caused by degenerative changes, such as bone spurs pushing against the spinal cord within the spinal canal or a disc herniation that pushes against the spinal canal. When the spinal cord becomes compromised within in the neck the condition is referred to as cervical myelopathy. This condition can cause problems with the bowels and bladder, change the way you walk, and affect your ability to use your fingers and hand and requires immediate medical attention.

Symptoms
Symptoms from neck problems vary as they depend on the affected structures involved.  Some of the more common symptoms associated with neck problems are:

• Neck pain
• Headaches
• Pain spreading into the upper back or down the arm
• Neck stiffness and reduced range of motion
• Muscle weakness in the shoulder, arm, or hand
• Sensory changes (numbness, prickling, or tingling) in the forearm, hand, or fingers

Diagnosis
The diagnosis of neck pain is based on your medical history and description of injury, clinical examination, diagnostic imaging such as X-ray, MRI, or CT scan, and, if warranted, electodiagnostic testing such as EMG to determine if there are any problems with the nerves going to the upper extremity.  When the source of the problem is thought to be of a non-mechanical nature, laboratory tests may be requested to rule out infection or arthritis.
 
Treatment
The treatment of neck pain is geared towards reducing pain and improving function.  Various treatment interventions for neck pain have been reviewed in the medical literature.  These include:

1. Medications
2. Cervical Collars
3. Ice and Heat Applications
4. Cervical Traction
5. Manual Therapy
6. Exercise Therapy
7. Ultrasound
8. Transcutaneous Electrical Nerve Stimulation (TENS)
9. Patient Education
10. Surgery

The consensus among medical researchers regarding the treatment of neck pain is 1.) Stay active and resume normal activities as soon as possible; 2.) Use painkillers and NSAIDs for a short period of time; 3.) Use manual therapy/mobilization techniques in combination with active exercise and patient education to accelerate pain reduction and restoration of normal movement.  With respect to passive modalities such as heat, ice, ultrasound, and cervical traction, there is insufficient evidence that these treatment interventions provide any benefit.

Cervical spine surgery is warranted if there are signs of pressure developing on the spinal cord or if your muscles are becoming rapidly weaker.  Otherwise, most neck pain conditions are conservatively treated for at least 3 months before surgery is ever considered.

When surgery is indicated, most orthopaedic spine surgeons utilize an anterior cervical fusion with a titanium plate as their gold standard of surgical choice.  This type of surgery is minimally invasive and provides a quicker return to function.

Summary
A review of the causes, diagnosis, and treatment of neck pain has been presented.  Although neck pain is becoming more and more common and, therefore, becoming an important medical problem, further research is needed to evaluate the efficacy and cost effectiveness of various treatment options for neck pain.
I welcome your input or questions below.

Written by Malton A. Schexneider, PT, MMSc