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13 Articles in Volume 12, Issue #9
PROMPT Challenges PROP’s Petition
PROP Answers Questions Raised About Opioid Label Changes
PROP vs PROMPT: Who Speaks for the Pain Doctor?
PROP’s Petition: PPM’s Editorial Board Weighs in
Assessment of Long-term Outcomes Of Opioid Treatment: How to Set Goals and Objectives
Extracorporeal Shock Wave Therapy: Applications in Pain Medicine—Part One
Neck Pain: Diagnosis And Management
Part Two: Trigeminal Neuralgia: A Closer Look at This Enigmatic and Debilitating Disease
Reducing Musculoskeletal Disorders Through Ergonomics
Risk Evaluation and Mitigation Strategy Compliance
Treating the Opioid-addicted Chronic Pain Patient: The Role of Suboxone
Electromagnetic Devices: A New Partner in Pain Management
Methadone Management in a Patient With Pain and History Of Addiction

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.

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

Red Flags

History and physical examination are essential to identify cases where more aggressive workup and treatment may be necessary. Table 2 highlights common red flags to be aware of. These should prompt clinicians to screen for ominous diagnoses. A diagnostic plan should be tailored to the individual’s presenting symptoms and findings, and often includes blood work such as a complete blood count test with differential, sedimentation rate, and C-reactive protein levels. In addition, imaging studies such as x-rays, bone scans, and magnetic resonance imaging (MRI) may also be necessary.

Differential Diagnoses

Although most common causes of neck pain are benign, it is important to consider broad differential diagnoses, particularly for those who require swift treatment and referral to specialists. Red flags only capture a sampling of the gravest diagnoses. Table 3 covers a wide range of diagnoses and suggests a corresponding management plan.

Diagnostic Tests

Imaging Studies

Neck pain associated with red flags or that persists beyond 6 weeks may benefit from radiographic evaluation. The Canadian Cervical Spine Rule (Table 4) is a helpful algorithm to further assess the need for imaging of neck pain after trauma.12 Routine imaging studies of nonspecific neck pain—such as plain x-rays and MRI—have a significant number of false positive findings, which often do not correlate with the patient’s symptoms and are therefore not indicated.13,14

  • Plain radiograph: Plain radiograph or x-ray is often the first imaging modality following an initial evaluation. Without a history of trauma, a 2-view examination (ie, anteroposterior, lateral) is sufficient. Flexion and extension views may be appropriate for symptomatic patients suspected of ligamental injury and spinal instability.15 The American College of Radiology does not recommend further imaging for patients with chronic neck pain and normal radiographic findings, unless neurologic signs/symptoms are present.16
  • MRI, computed tomography (CT) myelogram, and CT scan: Patients with neurologic signs/symptoms should proceed with MRI without contrast to assess for possible causes such as cervical disc herniation, cervical stenosis, and to rule out serious causes such as a spinal tumor and infection.17 MRI has high sensitivity for visualizing disc herniation and spinal/neuroforaminal stenosis.18 CT with myelogram is the alternative imaging choice for individuals with contraindications for MRI (ie, pacemaker, metal implants). CT scan alone is more specific with greater sensitivity for detecting fractures compared to plain x-rays.19 It is the initial modality of choice for high-risk trauma patients who sustain head injury, who are unable to follow directions, or who develop focal neurological deficits.20

Table 1. Provocative Tests Used During Physical ExaminationTable 2. Red Flags in History and Physical Examination

Electrodiagnostic Studies

Electrodiagnosis allows for physiologic evaluation of the nervous system. As an extension of physical examination, it can achieve the following purposes: (a) detect nerve pathology, (b) localize level(s) of involvement, (c) estimate timing of nerve injury, (d) prognosticate outcome, and (e) demonstrate electrodiagnostic evidence of recovery. Useful studies include:

  • Nerve conduction studies to rule out peripheral neuropathy
  • Electromyography (EMG) is the most sensitive study to assess for nerve root involvement, and has greatest yield 3 weeks after onset of symptoms.21 It has been suggested to have superior positive predictive value compared to MRI in the asymptomatic adults.22 However, the true diagnostic value of EMG varies significantly23
  • Motor- and somatosensory-evoked potentials assess for spinal stenosis, and may detect subclinical upper motor neuron signs24

Rehabilitation Concepts

A rehabilitative program can begin once serious etiologies of neck pain are ruled out, or patients are medically cleared to participate after treatment of such conditions. A working diagnosis based on the history and physical examination (with imaging studies to supplement as indicated) is used to guide the physician in providing a specific prescription for treatment. The guiding principle in neck pain rehabilitation is to encourage early mobilization and rapid return to normal activity level.25 With a handful of exceptions, the scientific evidence for common treatments of neck pain is poorly validated.26 Systematic reviews do however support multimodal treatments over any single modality.27

Table 3. Differential Diagnoses of Neck PainTable 4. Canadian Cervical Spine Rule

Phases of Rehabilitation

Regardless of modality choice, there are three phases in neck pain rehabilitation. The first is the acute phase, where pain control is the primary goal. It is achieved with a combination of medications, physical modalities, and avoidance of aggravating activities. Next comes the restorative phase, which focuses on recovering range of motion, correcting biomechanical deficits, and strengthening. Here, the patient transitions to a home exercise program and advance activity as tolerated in the final maintenance phase. During treatment, the physician should assess the patient’s progress through these three phases of treatment with intermittent follow-up visits. If progress is not made, the diagnosis should be reassessed and the treatment modified as necessary. This may include the use of medication or various injections based on the pathology in an effort to facilitate active treatment and progression to an independent home exercise program.

Conservative Management Options

Education and Relative Rest

Reassure patients that neck pain is a common problem and often resolves on its own within a few weeks.28 Avoiding painful positions for a few days before returning to a normal activity level is a reasonable option, but do stress the importance of early mobilization.29 A cervical pillow may also provide comfort at night. Strict rest and continuous use of cervical collar positions/activities are not necessary and even discouraged. For recurrent episodes, the clinician should assist the patient in identifying and correcting predisposing factors, which result in these painful episodes.30

Pharmacotherapy

While no studies have fully validated the efficacy of any medications in the management of neck pain, patients with significant pain may benefit from pharmacotherapy to allow for quick return to normal activities.31 Medication choice depends on individual profiles, and the options include:

  • Non-steroidal anti-inflammatory drugs (NSAIDs): The combined analgesic and anti-inflammatory properties make them common first-line agents.32 Moderation is advised to avoid unnecessary side effects and promote inflammation-mediated healing
  • Acetaminophen: Counsel on conservative daily intake in patients with alcohol abuse, advanced age, and concomitant anticonvulsant use33
  • Topical analgesic agents: Topical menthol, capsaicin, and camphor are widely available over the counter. Topical lidocaine has been used with some success as well.34 Topical NSAIDs have recently become available. These treatments have not been validated in patients with acute or chronic neck pain, but may be useful in patients with chronic soft tissue pain35
  • Muscle relaxants: The limited use of skeletal muscle relaxants may be considered in cases of muscle spasm and pain.36 The patients should be advised of the sedative effects of these medications
  • Steroids: A short taper is often prescribed for acute radicular pain and has been reported to be beneficial; however, the evidence for this is limited and routine use of oral steroids for neck pain should be avoided.37
  • Anticonvulsants and tricyclic antidepressants: Both classes of medication have been used adjunctively to reduce chronic neck and radicular pain.38,39 There are no studies to support their use in acute neck pain
  • Opioids: Opioids, such as tramadol and oxycodone, may be tried if other medications fail to provide adequate relief or are contraindicated40,41

Vitamins and Supplements

Various vitamins and supplements can also be used to control pain and allow for improvement in daily function. Some examples are:

  • Natural anti-inflammatory agents—omega-3 fatty acids,42 white willow bark,43 bromelain,44 and pine bark extract45
  • Bone/muscle health, fatigue, and cardiac/immune function—Vitamin D46,47
  • Arthritis/cartilage health—glucosamine with chondroitin sulfate48
  • Neuropathy pain/nerve health—Vitamin B6,49 α-lipoic acid,50 and acetyl-L-carnitine51

Manipulation and Mobilization

Spinal manipulation encompasses a range of techniques practiced by various providers (chiropractor, osteopath, physical therapist), but is specifically defined in a 2010 Cochrane Review as a therapeutic technique where a high-velocity thrust is directed to the spine; this definition is most consistent with chiropractic manipulation. Mobilization includes all non-thrust manual therapies (eg, muscle energy and strain–counterstrain techniques) designed to overcome restricted joints and lengthen shortened muscles. There is evidence showing that both modalities provide at least short-term benefit in patients with neck pain and are thus viable options.52 However, rare but serious adverse events, including secondary stroke, have been reported.53

Exercise Therapy and Physical Therapy

There is further evidence supporting the clinical efficacy of exercise combined with cervical mobilization/manipulation in acute and chronic neck pain.27,54 The relative benefits of specific exercise approaches, however, are not well defined because of poor characterization and inadequate samples in the literature. The general exercise regimen may include:

  • Stretching: Regular, prolonged stretching helps overcome soft tissue shortening and tightening that most commonly affect the anterior cervical and thoracic musculature
  • Strengthening and endurance: Progressive strengthening helps compensate for the relative weakness that most commonly plagues the posterior cervical, shoulder girdle, and scapular/thoracic musculature
  • Coordination: Proprioceptive training maximizes recovery and aims to prevent recurrence of neck pain

Physical therapy provides a structured, supervised program that guides patients to return to full activity. It can benefit patients who perform better in such an environment and/or who have significant range of motion deficit on presentation. In addition to stretching and strengthening, the therapy prescription may include the following:

  • Passive mobilization: The use of manipulation and myofascial release can be helpful initially to release the noncontractile elements of soft tissues
  • Mechanical traction: Intermittent, mechanical traction can be trialed for possible improvement of radicular symptoms
  • Stabilization: This aspect of therapy deals with posture re-education, optimizing dynamic positions, and incorporating patterned movements to achieve complex, functional tasks
  • Home program: Exercises that will help maintain strength and flexibility will be identified and incorporated into a regular home program

Acupuncture and Low Level Laser Therapy

Acupuncture has moderate evidence supporting short-term clinical benefits in neck pain present greater than 3 months.55 There are also currently a handful of randomized controlled trials suggesting good short-term clinical efficacy of low level laser therapy (LLLT) in patients with acute and chronic neck pain.56 LLLT uses a single-wavelength laser to reduce inflammation and possibly alter cellular function.57

Other Treatment Modalities

Massage, biofeedback, acupressure, ultrasonography, electrotherapy (eg, transcutaneous electrical nerve stimulation, electrical muscle stimulation, and pulsed electromagnetic therapy), diathermy, ethyl chloride spray and stretch, cervical traction, dry needling, and trigger-point injections are examples of various treatment modalities that are commonly used to treat neck pain. The clinical efficacy of these therapies is not supported by the current literature.26,58-61

Aggressive Management Options

Patients suffering from severe, chronic disability despite conservative management may consider more aggressive management options, such as:

  • Epidural corticosteroid injection: This procedure aims to reduce inflammation at the targeted spine level. It is used to treat neck pain due to cervical degenerative disc and facet disease. There is good evidence that patients with cervical radiculopathy and chronic disorder with radiation can achieve short-term benefit from epidural injections; however, it is not necessary to perform epidural injections in a “series” as there is no scientific evidence that this is necessary or of added benefit.62-64 Severe complications, although rare, have been reported65
  • Medial branch block: Medial branch block is a diagnostic—and on occasion, therapeutic—procedure that numbs the nerves supplying the targeted facet joint(s). There is good evidence that it can provide long-term and short-term relief66,67
  • Radiofrequency neurotomy: Radiofrequency denervates targeted medial branch nerve(s). If patients are confirmed to have facet-based pain by medial branch block, neurotomy can be pursued for long-term pain relief.66 Expected pain relief is between 9 months and 1 year68
  • Pulsed radiofrequency treatment: Pulses of currents can be delivered via an implanted electrode at a targeted level to modulate pain. In recent studies, it appears to have significant short- and long-term effectiveness for patients with chronic refractory cervical pain.69,70

Patients who fail to respond to nonsurgical managements may be surgical candidates.17 Surgery is best indicated in patients with radiculopathy with clearly identified pathology—for example, single-level disc herniation that corrlelates with the findings on history and physical examination. Procedures include laminectomy, discectomy, corpectomy, and fusion. With appropriate indications, surgery can result in resolution of symptoms and excellent outcomes in the majority of patients.

Conclusions

Neck pain is a common complaint presenting to primary, orthopedic, and other musculoskeletal specialists. The prognosis is very good for most patients. The clinician should perform a detailed history (which includes an assessment for red flags), perform a comprehensive examination, and obtain imaging studies only when supported by the history and physical examination. A working diagnosis based on the history and physical examination is often sufficient to guide the physician in determining a comprehensive treatment plan. This should be explained to the patient. Treatments include active physical therapy, medications, and in some cases injections to facilitate an active therapy plan. The goals of treatment are pain reduction and return of daily function. This should include a discharge to an independent home exercise and self-management program, which avoids an overreliance on passive treatments and repeated visiting to healthcare clinicians. In the author’s experience this approach is successful in the vast majority of patients treated.

 

Last updated on: October 31, 2012
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