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Neck Pain: Diagnosis And Management

Neck pain is an extremely common complaint among patients. This article reviews the anatomy, common causes, as well as practical approaches to the management of neck pain.
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Neck pain is a common complaint of patients presenting to a primary care office. Approximately 10% to 15% of the world’s population suffer from an episode of neck pain at any time and 40% of the population will suffer from neck pain over a 12-month period.1,2 Causes of pain vary from myofascial strain/sprain to myelopathy. Several guidelines on the management of neck pain have been published.3-6 However, there remains no definitive consensus on this topic. Although acute neck pain generally resolves with conservative treatment, an algorithmic approach should be applied to ensure a full assessment of this complaint.

Anatomic Cervical Spine

Functional Anatomy
The cervical spine consists of seven cervical vertebra and eight cervical nerve roots. The C1-C2 (atlantoaxial) joint forms the upper cervical segment, which allows for 50% of all cervical rotation. The occipitoatlantal joint is responsible for 50% of flexion and extension. Below the C2-C3 level, lateral bending of the cervical spine is coupled with rotation in the same direction. This is due to the 45° inclination of the cervical facet joints. The vertebral bodies of C3-C7 are similar in appearance and function (Figures 1 and 2). They articulate via the zygapophyseal or facet joints posteriorly. On the lateral aspect of the vertebral bodies are sharply defined margins, which articulate with the facet above. These articulations are called uncovertebral joints, or the joints of Luschka. These joints can develop osteophytic spurs, which can narrow the intervertebral foramina. Intervertebral discs are located between the vertebral bodies of C2-C7. The discs are composed of an outer annular fibrosis and an inner nucleus pulposus and serve as force dissipators, transmitting compressive loads throughout a range of motion. The intervertebral discs are thicker anteriorly and therefore contribute to normal cervical lordosis. The foramina are largest at C2-C3 and progressively decrease in size to the C6-C7 level. The nerve root occupies 25% to 33% of the foraminal space. The neural foramen is bordered anteromedially by the uncovertebral joints, posterolaterally by facet joints, superiorly by the pedicle of the vertebra above, and inferiorly by the pedicle of the lower vertebra. Medially, the foramina are formed by the edge of the end plates and the intervertebral discs. The nerve roots exit above their correspondingly numbered vertebral body from C2-C7; C1 exits between the occiput and atlas, and C8 exits below the C7 vertebral body. Degenerative changes of the structures that form the foramina can cause nerve root compression. This compression can occur from osteophyte formation, disc herniation, or a combination of the two.7

Sport-specific Biomechanics
Cervical radiculopathy in athletes can occur from several mechanisms. These injuries can occur from an extension, lateral bending, or rotation mechanism, which close the neural foramen and result in ipsilateral nerve root injury. Conversely, a traction injury can occur with a sudden flexion or extension, coupled with lateral bending away from the affected nerve root. Additionally, cervical disc herniations can occur with a sudden load with the neck in either flexion or extension. In elderly persons with osteophyte formation, repetitive neck extension and rotation in certain sports, such as swimming or tennis, may result in a more insidious injury.7


Figure 1. Illustrtion of a CV vertebraFigure 2. Illustration of the vertebra and soft tissues.

History and Physical Examination

Notable Components of History

  • Mechanism of injury: Inquire about how, when, and where the injury took place. If this is related to a motor vehicle accident, then the history should include where the patient was in the vehicle, whether they were wearing a seat-belt restraint, and whether they require emergency transportation and assessment at an emergency department. Pay particular attention to the position of the head and neck at the time of injury

  • Location and intensity of the pain: The use of a body pain diagram may be helpful to understand the pain distribution and characteristics, and may be helpful in directing further evaluation. Pain should be recorded using standard pain assessment scales such as the numeric pain scale, etc
  • Aggravating and relieving factors: Determine positions that worsen and improve the pain. Find out how the pain impairs a patient’s functional status at home and at work. All these factors should be taken into account when developing a comprehensive treatment plan
  • Neurologic symptoms: Examine the patient for the presence and location of neurologic symptoms, like numbness or tingling, as well as the duration. It is especially important to document any sensory loss, motor weakness, gait difficulties, or spasticity
  • History of prior neck injury or complaints: Be sure to take a careful medical history of all previous injuries or complaints

Algorithm. Approach to management of acute neck pain.

Notable Components of Physical Exam

  • Inspection: Inspect the position of the head relative to the body at rest. A forward head and rounded shoulder posture are common in patients presenting with myofascial neck pain. Note the presence of any skin lesion, atrophy, or fasciculation (muscle twitching) in the upper limbs
  • Palpation: Localize the most tender area(s) and identify the structures involved
  • Range of motion: Record range of motion of the cervical spine in flexion/extension, rotation, and lateral bending. Also note shoulder range of motion as neck and shoulder problems commonly overlap
  • Neuromuscular examination: This is arguably the most important aspect of the examination. It includes manual muscle testing, sensory testing, and reflex testing. In addition to asymmetrical deep tendon reflexes, the presence of pathologic reflexes (eg, Hoffmann’s [finger flexor reflex] and Babinski’s signs [upward extension of the toes after plantar reflex test]) is also important to evaluate
  • Provocative tests: Many specialized provocative tests are used in examination of the cervical spine and related neck structures and are purported to assist in identification of radiculopathy, spinal cord pathology, or brachial plexus pathology (Table 1)

The clinician should be aware of how to properly perform these tests as well as have an understanding of the sensitivity and specificity of these tests.8-11

Last updated on: October 31, 2012
First published on: October 1, 2012